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SKIN GRAFTING 



SKIN GEAFTING 



FOR SURGEONS AND 
GENERAL PRACTITIONERS 



BY 

LEONARD FREEMAN, B.S., M.A., M.D. 

PROFESSOR OF SURGERY IN THE MEDICAL DEPARTMENT OF THE 
UNIVERSITY OF COLORADO, SURGEON TO ST. JOSEPH'S HOS- 
PITAL, THE NATIONAL JEWISH HOSPITAL, AND THE 
CITY HOSPITAL, DENVER, COLORADO 



WITH ®i ILLUSTRATIONS 



ST. LOUIS 

C. V. MOSBY COMPANY 

1912 



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&h 



Copyright, 1912, by C. V. Mosby Company 



Press of 

C. V. Mosby Company 

St. Louis 



©CI.A332140 



CONTENTS 



CHAPTER I. 

PAGE 

Terminology — Early History 1-6 

Definitions — Early History. 

CHAPTER II. 

Comparative Vitality of Grafts from the Old and from 
the Yotjng — Heterogeneous Grafting — Dangers of 
Transferring Disease — Influence of the Patient's 
General Condition upon Skin Grafting — Surgical 

Cleanliness 7-12 

Grafts from the Old and from the Young — Heterogene- 
ous Grafting — Transmission of Disease — The Patient's 
General Condition — Death from Skin Grafting — Sur- 
gical Cleanliness. 

CHAPTER III. 
Tee Method of Reverdin 13-32 

Preparation — Where to Obtain Grafts — Size of Grafts — 
Method of Cutting Grafts — Placing the Grafts — Legal 
Questions — Dressings— Wet and Dry Dressings — Chang- 
ing Dressings — Process of Healing — After-treatment. 

CHAPTER IY. 
The Method of Thiersch — Its Use in Special Cases . . 33-67 
General Technic — Hemorrhage — Curetting — Preparation ■ 
of Granulations — Methods of Cutting Grafts — Placing 
the Grafts — Grafting in Two Stages — Thin vs. Thick 
Grafts — Anesthetics — Dressings — "Splinting" Grafts — 
Treatment of Wounds After Removal of Grafts — "Ac- 
cordion Grafts" — Proper Time for Grafting — After- 
treatment — Application of Thiersch Grafting — Thiersch 
Grafting in Special Cases — Heterogeneous Thiersch 
Grafting — Statistics. 



CONTENTS 



CHAPTEE V. 

PAGE 

The Wolfe-Krause Method 68-73 

Preparation — Technic — Adjustment of Grafts and Dress- 
ings — After-treatment. 

CHAPTER VI. 

The Method of Hirschberg — Skin-Periosteum-Bone 
Grafts 74-76 



CHAPTER VII. 

The Transplantation of Mucous Membrane — Anomalies 

in Skin Grafting — Sponge Grafting 77-83 

Mucous Membrane — Anomalies in Skin Grafting — 
Sponge Grafting. 

CHAPTER VIII. 

Grafting from Animals 84-89 

CHAPTER IX. 

Grafting in Lupus, in X-ray Burns, on the Cranium, 
and in Connection with the Eye and Ear .... 90-104 
Lupus — X-ray Burns — Grafting on the Cranium — The 
Eye— The Ear. 

CHAPTER X. 
Local Anesthesia in Skin Grafting 105-107 

• CHAPTER XL 

Histology and Pathology * 108-121 

Adhesion and Nutrition — Color — Mortality — Sensation 
— Cicatricial Contraction — Exfoliation — Depressions — 
Production of Epithelium — Independent Longevity of 
Epithelium — Epithelial Stimulation — Grafting from Ne- 
gro to White Man — Cheloids. 

CHAPTER XII. 

Brief Comparison of Different Methods of Skin Graft- 
ing . 122-125 



ILLUSTRATIONS 

FIGURE PAGE 

1 Incisions through indurated border and floor of callous ulcer 18 

2 Cutting a Reverdin graft 21 

3 Cutting a Reverdin graft 22 

4 Cutting grafts from pellicle of new skin at border of healing 

ulcer 23 

5 Reverdin grafts in place 24 

6 Reverdin graft in place at the end of planting 25 

7 Strip of rubber tissue with punched-out drainage holes . . 27 

8 Strip of gauze pinned about the leg for holding grafts in 

place 28 

9 Cutting Thiersch grafts from thigh 34 

10 Thiersch graft partially cut 35 

11 Showing how Thiersch grafts should overlap each other . 36 

12 Thiersch grafts in place 36 

13 McBurney's hooks for stretching skin 41 

14 Halsted method of cutting large Thiersch grafts .... 42 

15 Sliding Thiersch graft from razor on to surface of ulcer . . 44 

16 Placing Thiersch grafts from razor 45 

17 Wire cage in place in open method of grafting 49 

18 Wire cage in place in open method of grafting 50 

19 Wire cage for open method of grafting 50 

20 Method of "splinting" grafts with netting 52 

21 Accordion grafts 54 

22 X-ray dermatitis of hip 94 

23 X-ray burn of hand 94 

24 Points for insertion of local anesthetic in skin grafting . .106 



SKIN GRAFTING 



CHAPTER I 
. TERMINOLOGY— EARLY HISTORY 

Definitions. 

Skin grafting should not be confused with plastic surgery 
(anaplasty), as is frequently clone. The former refers to 
operations in which portions of skin or of epithelium are 
entirely severed from their original connections and used 
to fill in defects elsewhere ; while the latter should be 
limited to procedures where flaps of skin are employed 
which are merely loosened from the underlying tissues and 
slid from one point to another, or are provided with pedi- 
cels through which nutriment is furnished until union 
takes place. 

The simplest form of plastic work consists in "mobiliz- 
ing" the integument adjoining a wound in order to relieve 
tension and facilitate the application of sutures. The 
most complicated is perhaps that introduced by Schrady, 1 
in which a skin-flap is made to adhere to the denuded side 
of a finger, so that when the original connections are sev- 
ered the flap may be conveyed, attached to the finger, to 
any portion of the body— the digit serving as a sort of 
movable pedicel. 

1 Medical Record, Jan. 24, 1891, p. 117. 

1 



SKIN GRAFTING 



Transplantation is another term for skin grafting. Im- 
plantation means practically the same as transplantation 
(Gould), although its use is often limited to operations in 
which dead organic or inorganic substances are employed. 
D ermanoplasty (Esmarch) and dermepenthesis are some- 
what obsolete synonyms for skin grafting. The w^ord flap 
should be confined to plastic surgery, and the word graft, 
to transplantation. 

Transplantation is sometimes designated as the first or 
older Indian method, in contradistinction to the second 
Indian method, often called simply "Indian method," in 
which a pedunculated flap, with more or less twisted pedi- 
cel, is taken from the adjacent tissues. In the Italian 
method, the flap is obtained from one of the extremities 
which can be brought in contact with the field of opera- 
tion — for instance, the arm in rhinoplasty. 

When grafts are composed of epithelium alone, whether 
in the form of large or of small pieces, or of so-called 
"epidermal dust," they are known as epidermal grafts; 
when comprising both epidermis and a portion of the true 
derm, as der mo-epidermal grafts; and w T hen made up of 
the entire thickness of the skin, whether including the 
subcutaneous connective tissue or not, as total cutaneous or 
"whole-thickness" grafts. 

Vegetable grafting, termed instition, by Kiister, has little 
in common with skin grafting, in spite of a superficial 
similarity. Vegetable grafts grow upon their hosts from 
first to last as separate individuals, something in the 
nature of parasites. Skin grafts, on the contrary, become 
a portion of the tissue into which they are transplanted. 
Such experiments, however, as the one made by John 



EARLY HISTORY 



Hunter, a hundred years or more ago, of transplanting the 
spur of a cock to the comb of the same fowl, has a strong 
resemblance to vegetable grafting. 

When grafts are obtained from the patient himself, they 
are preferably called aidodermic ; when from another in- 
dividual, lietero-, homo-, or isodermic; and when from 
animals, zoodermic — the methods being known as auto- 
plastic, heteroplastic, and zooplastic. 



Early History. 

Surgery is usually regarded as a modern science, and yet 
the ancient Hindus, perhaps two thousand years ago, per- 
formed many difficult operations as successfully as we per- 
form them now. Particularly is this true of some forms 
of plastic surgery and of skin grafting. 

It was the custom in India to punish certain offenses by 
cutting off the nose. As an almost necessary consequence, 
there appeared at an early date men skilled in plastic 
surgery, who belonged, strangely enough, to a low and 
despised class, the tile-maker's caste. Their work is said 
to have been excellent, even superior in some respects to 
that done at the present time. One of the most remark- 
able achievements of these pioneers in surgery was the 
replacement of the nose by a graft from the thick skin 
of the gluteal region, a feat which even now cannot be 
repeated with certainty. When we consider that the sub- 
cutaneous fat was included and that no support could have 
been had from underlying tissues, the success obtained 
seems little short of marvelous. The temptation is great 
to ascribe some virtue to the secret "cement" employed, 



4 SKIN GRAFTING 

but we know so little of the actual technic that speculation 
in this line is not of much value. 

Tt was once thought that pieces of skin transplanted from 
one individual to another grew vigorously or withered as 
the original possessor's health became good or bad. Hence, 
it may be imagined that the man bearing such a graft 
must often have been very solicitous as to the physical 
welfare of the donor. 

It is probable that skin grafting, like some other arts, 
was largely lost sight of during the middle ages, although 
here and there a more or less authentic account of an 
isolated case has been preserved. For instance, it is re- 
lated by Sancassani (1731 to 1738), that a female street- 
vender, in order to prove the efficacy of a certain salve, was 
accustomed to cut a piece of skin from her leg, pass it 
around the audience upon a plate, and then replace it in its 
original position, covering it with salve. Such perfect 
union took place that the site of the operation was scarcely 
discernible. 

About the end of the eighteenth century some account 
of the Indian methods of grafting was brought to Europe 
by travelers. The statements, however, were credited by 
few, and those who did believe were generally disap- 
pointed when they tried the experiment themselves. 
Nevertheless Van Helmont 2 states that Tagliacozza, a 
Bologna surgeon famous for his achievements in rhino- 
plasty, constructed a nose for a patient in Brussels from 
the skin of the arm of a workman; but Tagliacozza has 
been credited with so many wonderful things that it is 
difficult to sift the true from the false. 

2 Opera Omnia, 1682. 



E^KLY HISTORY » 

The skin from the back of a student's hand is said to 
have been used by Dzondi in the formation of a woman's 
nose, and Biinger 3 succeeded in getting a portion of a 
graft from the thigh to adhere in a similar operation. 

And yet, while disbelief was almost universal, it must 
have been generally known among medical men that cer- 
tain parts — such as noses and fingers^ when accidentally 
severed from their connections — were capable of becoming 
reunited under favorable circumstances. In fact, records 
of such cases are not uncommon in the writings of various 
ages, and one would imagine that the conception of skin 
grafting, based upon such a foundation, would have been 
almost unavoidable. John Bell, 4 however, scornfully 
mentions two instances, regarding them as fabrications; 
and yet they may well have happened. The first was 
described by Garengeot as follows: 

A soldier, reeling out of a tavern drunk, along with some of his 
companions, got into a quarrel, in which one of them bit his nose off, 
threw it into the gutter and trode it under foot. He picked up his 
nose, flung it into Mr. Gallin's, an apothecary's shop, ran after the 
fellow who had done it, and when he returned, Mr. Gallin washed the 
nose at the well, stuck it with plaster in its place, and in two days 
after it was firmly united. 

The second instance was related by Sir Leonard Fiora- 
vanti : 

In that time when I was in Africa there happened something 
strange and this was it. A certain gentleman, a Spaniard, that was 
called Seignior Andrew Gruitiero, of the age of twenty-nine years, upon 
a time walked in a field with a soldier, and had words with him and 
began to draw. The soldier seeing that, struck him with the left 
hand and cut off his nose, and then it fell down in the sand, and 
then I happened to stand by and took it up, and washed away the 

3 Graf e and Walther's Jour., 1823. 

* Principles of Surgery, London, 1826. 



6 SKIN GRAFTING 

sand, and stitched it on again very close and dressed it with our 
balsam um artificiato', and bound it up and so let it remain eight 
days, thinking that it would have come to matter, nevertheless, when 
I did unbind it, I found it fast conglutinated, and then I only dressed 
it once more, and he was perfectly whole. 

A unique feature of this interesting narration is the fact 
that the sand was removed from the severed part by 
urinating upon it — certainly an easy method of procuring 
a supply of sterile salt solution ! 

So firm was John Bell in his belief that no portion of the 
body could grow on again after it had once been completely 
removed, that when confronted by a man who had chopped 
off the end of a finger and successfully replaced it, Bell 
tried to explain the circumstance by supposing that "so 
small a piece of the finger may have rotted after it was 
bandaged, the remaining flesh upon the point of the finger 
growing up to supply its place." What would this eminent 
surgeon have thought had he come in contact with a case 
similar to one reported by Finney 5 in which a finger be- 
came reunited after being completely severed from the 
body some seven hours, or the case observed by Kelley 6 
where the soft parts of a nose grew in place after having 
been separated an hour? As early as 1836, Hoff acker, 7 
surgeon to a students' duelling corps in Heidelberg, suc- 
ceeded in reuniting numerous severed portions of noses and 
a piece of a lip. 

5 Johns Hopkins Hosp. Bull., Oct.-Nov., 1892. 

6 Times and Register, Phila., Aug. 16, 1890. 

7 Med. Annalen, 1836. 



CHAPTEE II 

COMPARATIVE VITALITY OE GRAFTS FROM 
THE OLD AND FROM THE YOUNG— HETERO- 
GENEOUS GRAFTING— DANGERS OF TRANS- 
FERRING DISEASE— INFLUENCE OF THE 
PATIENT'S GENERAL CONDITION UPON 
SKIN GRAFTING— SURGICAL CLEANLINESS 

Grafts From the Old and From the Young. 

It has often been stated that grafts taken from the old, 
especially when including the entire thickness of the skin, 
do not grow so well as those removed from younger individ- 
uals, even when the transplantation is made from the 
patient's own body. Most of these assertions, however, are 
based upon an article by Dobson, 1 whose experiments were 
limited to but one graft in one case. More recently others 
have made similar claims, with somewhat more ground for 
their assertions, and Sullivan 2 says that experience has 
taught him that skin from babies, particularly those at 
the breast, is possessed of superior vitality. Ivanova has 
utilized this idea in grafting from the bodies of dead 
infants. 

Many successful graftings are, nevertheless, done upon 
individuals well advanced in years ; and not only that, but 
they are done under unfavorable conditions, as in ulcers 
of the leg. Even admitting that grafts from the young 

1 Medical Times and Gaz., Oct. 29, 1870. 

2 Med. Rec, Jan. 9, 1897, p. 48. 



8 SKIN GRAFTING 

may show a somewhat greater vitality than those from the 
old, there is not sufficient difference in this regard to 
warrant either a refusal to operate upon old people or an 
attempt to invariably employ in such cases skin taken 
from the young. 

Heterogeneous Grafting. 

There is no doubt that grafts thrive best when obtained 
from the patient's own body, but nevertheless grafting 
from others may be successful, although many of the mar- 
velous cases described in the daily press are either exag- 
gerated or have been reported too soon to be scientifically 
reliable. Although the grafts may apparently flourish at 
first, many of them, even when derived from blood rela- 
tions, are apt ultimately to disappear in two or three weeks, 
with or without suppuration. 3 This was exemplified in 
one of the writer's cases, in which a large bum was covered 
by grafts partly obtained from the patient's thighs and 
partly from those of his mother. Every one of the auto- 
dermic grafts survived while all of the isodermic transplan- 
tations ultimately perished. 

Davis 4 has recently reported forty cases of isodermic 
Thiersch grafting with nineteen complete successes, sixteen 
partial successes, and but ixve failures. In his opinion, 
"isodermic grafts are quite as successful as those from the 
same individual under similar favorable conditions," but 
the experiences of many others do not warrant so optimistic 
a conclusion ; and it is undoubtedly safer, from all points of 
view, to transplant from the patient's own body. Heter- 
ogeneous grafting shoul'd always be done when possible 

3 Lexer, Zent. f. Chir., 1911, -No. 29, p. 23. 
* Ann. Surg., 1909, Vol. 50, p. 542. 



TRANSMISSION OF DISEASE \) 

under local anesthesia, in order to avoid danger to the 
donor of the skin. Schaefer 5 thinks that heterogeneous 
transplantations do best when donor and recipient are of 
about the same age, but the accuracy of this view may well 
be questioned. 

Transmission of Disease. 

There is no doubt, that diseases of various kinds can be 
transmitted in skin grafting from one individual to an- 
other ; and in fact, this has been done in numerous in- 
stances: Syphilis is most to be feared. Deuvel 6 reports 
the case of an old gentleman with a large ulcer following 
erysipelas, which was grafted from a number of different 
persons, including his son. The patient soon developed 
syphilis, originating in the grafted area. Upon investi- 
gation, the son was found to be afflicted with the disease in 
its secondary stage. Such unfortunate accidents may be 
guarded against, however, by obtaining a preliminary 
Wassermann reaction. 

Czerny 7 mentions two cases, which are, however, not 
convincing, in which tuberculosis was thought to be trans- 
mitted by grafts obtained from legs which had been am- 
putated for white-swelling of the knee. The patients 
developed phthisis, although no signs of the disease had 
existed before, and the family histories were clear. 

Smallpox is said to have been inoculated through skin 
grafting in at least one instance; and as far as the other 
acute infectious diseases are concerned, the list is probably 
limited by lack of opportunity only. 

5 Tr. Internat. Med. Cong., 1887. 

6 Union Med., Dec. 11, 1881. 

7 Verhand. d. Deut, Gesell. f. Chir., 1886; Cent, f. Chir., 1886, No. 24. 



10 SKIN GRAFTING 

Halm 8 has shown, by an experiment for which he has 
been severely censured, that cancer may be transplanted 
from one portion of the body to another. He grafted an 
area of skin from an inoperable carcinoma to the surface 
of a wound made elsewhere, thus producing a malignant 
growth at the point of implantation. Similar experiments 
have since been repeated many times by others, and auto- 
inoculations have often been observed following operations 
for cancer. 

The Patient's General Condition. 

This is not of so much importance as a contraindication 
to grafting as might be supposed. On the contrary, the 
correction of a local septic process by transplantation can 
materially assist in the regaining of health and strength. 
Wounds may heal and grafts grow in a satisfactory manner 
upon those whose physical status is much below par, unless 
some specific poison be present. 

Erysipeolas can cause grafts to dissolve even after adhe- 
sions have taken place ; hence transplantations should not 
be made for perhaps six or eight weeks after the disease 
has disappeared, as streptococci are capable of existing for 
a long time within the tissues. Any acute fever, especially 
one of the exanthemata, may act in a more or less unfavor- 
able manner. 

It can scarcely be doubted that diabetes and nephritis 
exercise a somewhat unfavorable influence ; and yet success- 
ful grafting has been done in the presence of these condi- 
tions, and they need not deter us from operating in the 
absence of other contraindications, although, for obvious 

8 Ber. Klin. Woch. No. 21, 1888, p. 413. 



HSTFLTJEOSrCEl OF DISEASE 11 

reasons, local rather than general anesthesia shonld be 
chosen. 

Of all constitntional disorders, syphilis is probably the 
most disturbing, so much so that it has been claimed that 
grafting shonld never be attempted when this disease is 
present, and Hartley 9 cites several cases which he thinks 
show that grafts will not adhere until syphilis has disap- 
peared from the system. Much depends, of course, upon 
the stage of the trouble, and upon whether the surface 
which is to receive the grafts is directly syphilitic. 
Wounds often heal readily in syphilitics, and there would 
seem to be no reason why grafts should not grow ; in fact, 
they frequently do so, as has been demonstrated by the 
writer and by others. Nevertheless, it is wise to subject 
the patient to a preliminary course of antisyphilitic treat- 
ment lasting at least three or four weeks, particularly if 
the disease is active. Grafting on genuinely specific ulcers 
is not to be thought of, as it will almost certainly be fol- 
lowed by failure. 

Death From Skin Grafting. 

A case in which death followed the transplantation of 
skin to the surface of a large burn is reported by Dunn. 10 
He suggests that a fatal toxemia was produced by dis- 
turbance of the granulations ; but suppuration had been 
in existence for a year, and it is possible that amyloid 
disease may have been responsible for the accident. The 
urine was not examined. 

It is well established that skin grafting is an extremely 
safe procedure. The small mortality which accompanies 

9 N. Y. Med. Jour., Aug. 27, 1892, p. 247. 

10 Northwestern Lancet, Apr. 15, 1893. 



12 SKIN GRAFTING 

it being due to extraneous causes and not to the operation, 
itself. 

Surgical Cleanliness. 

This is of much importance, because the more nearly the 
surface to be grafted approaches an aseptic condition the 
greater is the likelihood of success ; and if the skin from 
which the cuticle is obtained is not cleansed, infection may 
result with more or less disastrous effects. 

Just as in other surgical operations, the cutaneous sur- 
face should be shaved, scrubbed, and rubbed with alcohol. 
Strong antiseptics, such as bichlorid of mercury, are un- 
necessary ; but if they are used, they must be washed away 
with care, as the presence of even a small quantity may 
interfere with the vitality of the grafts. For this reason, 
the iodin method is not often employed in skin grafting. 

The edges of cutting instruments, such as razors and 
knives, are injured by. boiling ; hence they are best sterilized 
by placing them in pure carbolic acid, afterward rinsing 
them in alcohol, which in turn is removed with salt solution. 

Although asepsis is undoubtedly desirable, it must not be 
supposed that it is always necessary to success. Trans- 
plantations will often adhere in the presence of the most 
profuse suppuration, providing the granulations are in 
reasonably good condition. In fact, in the grafting of 
ulcers and granulating wounds, it is seldom possible to pro- 
cure even an approximately aseptic surface, although more 
or less successful attempts are often made in this direction, 
as described in detail under the various methods of graft- 



CHAPTEE III 
THE METHOD OF REVERDIN 

Skin grafting is really one of the oldest procedures in 
surgery; and yet, so far as modern times are concerned, 
we knew little or nothing about it until Dec. 8, 1869, when 
J. L. Keverdin, 1 an interne of La Charite, in Paris, made 
his famous report on the subject to the Societie de Chirurgie, 
in which he claimed that bits of skin, completely severed 
from their original connections, would adhere and grow 
upon granulating surfaces. Others had reported similar 
experiments prior to this, however, to which scant attention 
had been paid. 

The principle was so audaciously new that many medical 
men of prominence in England and upon the Continent 
sneered at the discovery and greatly underrated its value, 
claiming that it was a painful operation which made new 
wounds and distracted attention from legitimate treatment 
of the old ones. Even David Page, 2 president of the Royal 
Medical Society of Edinburgh, with the usual fatuity of a 
medical prophet, said that skin grafting was "not likely to 
occupy a permanent position in minor surgery." 

Pollock 3 was among the first to adopt Reverdin's dis- 
covery in England, being rapidly followed by Bryant and 
others. Hodgen 4 and Munoz were two of the earliest 

1 Bull de la Soc. de Chir., Dec. 10, 1869. 

2 Brit. Med. Jour., Dec. 10, 1870 — Archiv. Gen. de Med., 1872. 

3 Trans, of the Clin. Soc, London, 1871. 

4 St. Louis Med. and Surg. Jour., July, 1871. 

13 



14 SKIN GRAFTING 

writers on the subject in America. In France, Reverdin's 
claims were soon abundantly established, and skin grafting 
became very popular. 

From sneering indifference, the surgical world then 
passed to overcredulity, in which exaggerated notions were 
held regarding the possibilities, of the discovery. It was 
frequently stated that the new skin was identical with 
normal cuticle, and that one need have no hesitation in 
making the most extraordinary promises in this regard, 
even in operations about the face and other exposed por- 
tions of the body. We now know, however, that the limi- 
tations of the method are great, and that its use should be 
restricted to certain cases only where the cosmetic results 
are of minor importance. 

It is often asserted that Hamilton, of New York, con- 
ceived the idea of skin grafting in 1847, and put it into 
execution on January 21, 1854, many years before Rever- 
din published his experiments, and Parmenter 5 even goes 
so far as to designate the process the "Hamilton-Reverdin 
Method." But if Hamilton's reference to his own opera- 
tion is referred to, 6 it is at once evident that what he per- 
formed was not a Reverdin operation, or even skin graft- 
ing at all, in the proper sense of the term, but merely a neat 
piece of plastic work in which he partially covered a crural 
ulcer with a pedunculated flap from the other leg. Hamil- 
ton, however, stated the important principle that it is un- 
necessary to cover a granulating surface completely in order 
to procure cicatrization, the new skin having a tendency to 
increase in area and fill in the deficiencies. He designated 
his procedure elk o plasty. 

5 Surgery by American Authors, Roswell Park, 1896. 

6 N. Y. Med. Jour., Sept. 1871, p. 225; N. Y. Med. Gaz., Aug. 20, 1870. 



THE METHOD' OF REVERMN 15 

Preparation. 

Some attention must be paid to the surface to be grafted, 
in Reverdin's method, in order to insure reliable results, 
although, this is of less importance than in other procedures. 
With fresh wounds and "healthy" granulating surfaces 
little preparation is requisite, but under more unfavorable 
conditions it is quite necessary. 

Bryant 7 recognized that it was possible for epithelium 
to grow upon an unhealthy granulating surface. In fact, 
the majority of Eeverdin grafts are applied in the pres- 
ence of more or less pus, and they have been known to 
thrive even upon the ulcerating surfaces of cancers 
(Kraske). It is nevertheless true that the healthier the 
granulations the greater the chance of success. One would 
hesitate before grafting upon tuberculous ulcers or those 
directly due to syphilis, and certain other conditions 
should be regarded in a similar manner. Ulcers in which 
the granulations are large and pale ("indolent," "exuber- 
ant," "succulent,") are unfavorable, as are likewise those 
presenting patches of necrotic tissue. 

The granulations should be of medium size, vascular, 
and of a fresh red color; not large and "flabby" or small, 
hard, and "irritable," as is sometimes found in ulcers pos- 
sessing little tendency toward healing. One of the best 
indications of fitness for the reception of grafts is the for- 
mation of a pellicle of new skin around the borders of an 
ulcer. It has been claimed by some that grafting should 
never be attempted unless such a pellicle exists, but this is 
undoubtedly going too far. Nevertheless, excavated ulcers 

7 Guy's Hosp. Reports, 1872, p. 237. 



16 SKIN GRAFTING 

and those with undermined edges do not usually present 
surfaces fitted for transplantation. It has been asserted 
that no pus should be present. Desirable as such an aseptic 
condition undoubtedly is, in the majority of instances it is 
unnecessary or practically impossible of realization. 

It is generally sufficient, then, that suppuration is not 
too profuse, and that the pus is "laudable" in character; 
but if actual or at least relative asepsis is desired, it may 
be secured by mopping with pure carbolic acid, scraping 
away the granulations down to the firm tissues beneath, and 
then dressing with a layer of gauze, over which is smeared 
sterile boric acid ointment. In twenty-four to forty-eight 
hours a healthy granulating surface suitable for grafting 
is obtained. 8 Painting with tincture of iodin is also 
effective. (See chapter on Thiersch Grafting.) 

The cicatricial tissue, which often surrounds the 
margins of old ulcers and lines their bases, encapsulating 
them, as it were, interferes decidedly with the vascular 
supply and may render skin grafting difficult if not im- 
possible. Sometimes this tissue is so dense that suitable 
granulations refuse to form, and the surface of the ulcer 
remains comparatively smooth and bloodless, as though 
scooped out of cartilaginous material. Inflammation of 
the surrounding skin or of the ulcer itself is also prejudi- 
cial to success. 

If the circulation be impaired by cicatricial tissue or 
by varicosities, or if marked inflammatory changes be pres- 
ent, complications which are more likely to occur when 
the ulcer is on one of the lower extremities, the patient 
should remain in bed until the part regains as far as pos- 

8 J. S. Davis, Internat. Jour. Surg., June, 1910. 



THE METHOD OF REVERDIN 17 

sible its normal tone. This may require from a few days 
to several weeks. 

Gauze compresses wrung out of warm salt solution or 
weak bichlorid of mercury are of use in allaying inflam- 
matory processes. Carbolic acid should not be employed, 
for this purpose, as its prolonged contact with tissues having 
at the best a deficient vitality may do more harm than 
good, as has been sufficiently demonstrated in connection 
with gangrene of injured fingers produced by weak solu- 
tions (2 per cent). Moderate pressure, applied evenly 
with a roller bandage, is generally of value. 

When all necrotic tissue has disappeared, and acute in- 
flammation has been allayed, the granulations should be 
prepared for reception of the grafts, providing the con- 
ditions are not already satisfactory. This is best done 
in most cases by cauterization and compression, em- 
ploying stick nitrate of silver or tincture of iodin for the 
former and a. roller bandage for the latter. Between the 
cauterizations, which should take place every two or three 
days, compresses wet with bichlorid, liquor sodse chlor- 
inata, or 0.5 per cent chloral, may be placed upon the 
ulcer, or else boric acid, aristol, or acetanilid salve, or per- 
haps these substances in the powdered state. Iodoform 
gauze saturated with balsam of Peru sometimes does good 
service. Where there is a tendency to acute eczema, dry 
dressings with talcum powder are often preferable. A 
daily washing of the part in warm soapsuds may be de- 
sirable when there is considerable discharge. 

When induration and fibrous thickening of the borders 
of the sore exist, absorption may be induced by compres- 
sion applied with imbricated strips of adhesive plaster or 



18 SKIN GRAFTING 

by means of a coin bound rather firmly against the part. 
Sometimes a few radiating incisions through the ring 
of callus down to the softer tissues beneath are of service 
in relieving tension and favoring vascular supply (Fig. 
1). These incisions may at times be continued through 
the thickened floor of the ulcer itself, and are usually not 
very painful owing to the obtunded sensibility of the tis- 
sues. A number of small parallel incisions are valuable 




Fig. 1. — Incisions through indurated border and floor of " callous ulcer." 

for the purpose of loosening up the indurated floors of cer- 
tain old ulcers. 

For the purpose of cleaning up old ulcers and stimu- 
lating their granulations, Eichard Harte often employs an 
aseptic flaxseed poultice, held firmly in place by the elastic 
pressure of a thin rubber bandage. 

Any strong antiseptics which may have been used for 
cleansing must be washed away before transplantation is 
begun, for fear of injuring the vitality of the grafts. 

Where to Obtain Grafts. 

When possible, the grafts should be obtained from the 
patient's own body rather than from another, not only be- 



THE METHOD OF REVERDIN 19 

cause they are apt to grow better, but because there is less 
risk of conveying disease. "Whether there is any advantage 
in employing skin from a region corresponding to the one 
operated upon is doubtful, although this point has been 
insisted upon by Lewis, 9 Agnew, 1 . Hueter, 11 and others. 
Donnelly, for some unexplained reason, prefers grafts 
from a portion of the skin subject to slight motion, such 
as the insertion of the deltoid muscle. 

There is an object, however, in grafting from the inside 
of the arm or thigh, or the side of the chest or bend of the 
elbow ; for in these situations the skin is thin and soft and 
comparatively free from hairs or glands. But practically 
skin from any convenient part of the body may be em- 
ployed with almost equally good chances of success — even 
the delicate new skin from the borders of ulcers which have 
begun to heal (see p. 23). The anterior surface of the 
thigh is often selected. 

Lucas 12 considers that "the prepuce of a child possesses 
a germinal vitality which renders it peculiarly serviceable 
for grafting," in addition to suppleness, thinness, and vas- 
cularity. He claims that preputial grafts will adhere 
when those from other parts fail, even on unhealthy gran- 
ulating surfaces. However this may be, the suggestion is 
of value in cases where sensitive patients, children for in- 
stance, strongly object to grafting from their own persons; 
but great caution must be exercised in order to avoid the 
carrying of disease. The material can be obtained in 
abundance in children's hospitals, just where it is most 
needed. 

9 Phila. Med. Times, March 21, 1874, p. 389. 

10 Med. and Surg. Reporter, Nov. 28, 1874, p. 424. 

11 Allgem. Chir., 1889. 

12 Lancet, Oct. 4, 1884, p. 586. 



20 SKIN GRAFTING 

Pusey 13 claims many advantages for the loose re- 
dundant skin of the scrotum ; but in the Eeverdin method, 
at least, it is difficult to understand how anything can be 
gained by procuring grafts from this situation or from the 
prepuce, although it might be otherwise in the method of 
Wolfe. 

Before cutting the grafts, whatever be the situation 
selected, the skin should be carefully cleansed, and the in- 
struments sterilized; for, although the wounds are small, 
they are nevertheless wounds, and should be guarded 
against infection. 

It is probably neither necessary nor desirable to irritate 
the skin by brushing or beating, with the idea of increasing 
its supply of blood and serum, as was practiced by the 
Hindus. Fowler, Ilirschberg, Granbury, and others have 
nevertheless recommended this, while Berger applies a 
mustard plaster or a poultice for the same purpose. 

Size of Grafts. 

The grafts should be small, about the size of a grain of 
wheat, as originally recommended by Eeverdin. JSTot that 
larger ones will not grow, as was early demonstrated by 
Oilier and others, but one of the principal claims of the 
Eeverdin method is that pain and scars are reduced to a 
minimum, which would not be true if the grafts were 
unnecessarily large. In addition, small grafts generally 
answer the purpose as well as larger ones, and the latter 
are apt to produce unsightly lumps. If the portions of 
skin are originally too large, they may be spread upon the 
thumb-nail and divided. 

13 Lancet, Oct. 18, 1884, p. 676. 



THE. MEiTHOB OF REVERDIN 



21 



Method of Cutting Grafts. 

Grafts are most easily cut by elevating a small fold of 
skin with a pair of mouse-tooth forceps and dividing it 
with scissors curved on the flat or with a knife or razor 
(Figs. 2 and 3). Iridectomy scissors are convenient for 
the purpose. The entire epithelium and a portion of the 
corium, perhaps one quarter to one half of a line in thick- 
ness, is thus obtained. None of the subcutaneous cellular 




Fig. 2. — ■ Cutting a Reverdin graft. 

tissue and fat should be included, as it does not possess 
sufficient independent vitality. The epidermis alone is all 
that is really necessary, although better results are per- 
haps obtained if a portion of the corium be included. 
Reverdin employed the term "greffe dermique" which 
Poncet changed to "greffe dermoepidermique/' thus more 
correctly expressing what is really meant. 

An insignificant oozing of blood results. The trifling 
amount of pain can be obviated, if necessary, by partially 



22 



SKIN GRAFTING 



freezing the skin with chlorid of ethyl or by anesthetizing 
the cutaneous surface by the injection of novocain. (See 
chapter on Local Anesthesia in Skin Grafting. ) When par- 
tial freezing is resorted to, the necessary number of grafts 
may all be cut at once and placed until needed in warm 
physiological salt solution, or raw-side down upon a warm 
piece of glass, which prevents the edges from curling under. 




Fig. 3. — Cutting a Reverdin graft. 

The little wounds are, from the method of cutting, more 
or less elliptical, which favors rapid healing, with the for- 
mation of a small, almost punctate, white scar. Sutures 
are unnecessary. An ordinary aseptic or antiseptic dress- 
ing should be applied, dry or moist, according to preference. 
A good one consists of boric acid ointment covered with 
rubber protective. The neglect of this precaution may per- 
mit the development of erysipelas or other infectious 
troubles. 



THE METHOD OF EE.VEEDIN" 



23 



Satisfactory grafts may often be cut by pressing a pair 
of curved scissors firmly against the skin and snipping off 
the portion which protrudes between the blades. 14 Some' 
prefer to elevate a fold of skin by transfixion with a fine 
needle, bnt this offers no advantage over forceps. Special 
skin grafting scissors were introduced by Bryant and by 
Smith, but they are entirely unnecessary. 

Souchon 15 has recently emphasized an old and useful 




Fig. 4. — Cutting grafts from pellicle of new skin at border of healing ulcer. 



method of obtaining small grafts by cutting them with 
scissors from the thin, new epithelium as it "floats" out 
from the skin-edges of a healthy granulating surface which 
is beginning to heal (Fig. i). 

The surface to be grafted is nearly always granulating 
and covered with more or less pus. ' The method of Rever- 
din, however, is also applicable to fresh wounds, although 

"W. H. Marcy, Med. Rec, Aug. 18, 1894, p. 206. 
15 J. A. M. A., July 17, 1909, p. 207. 



24 SKIN GRAFTING 

other procedures, such as those of Thiersch and Wolfe, 
give better results. 

Placing the Grafts. 

There is no object in scraping away the granulations, as 
is often done in the process of Thiersch. In fact, the only 
excuse for using the Eeverdin method is its comparative 
painlessness and insignificance as an operation; and this 
advantage would disappear if so harsh a procedure as cu- 
retting were resorted to, and little if anything would be 
gained. 

All that is necessary, then, is to wash away the pus as 




Reverdin grafts in place. 



thoroughly as possible with salt solution or sterilized 
water, using cotton sponges if desired, but avoiding hem- 
orrhage. Mild antiseptics which do not coagulate albu 
min may be employed without injury, providing they ar<> 
subsequently removed with some neutral solution, but it is 
questionable if any benefit is derived. A suppurating, 
granulating surface cannot be sterilized by the brief use 
of ordinary antiseptics, and it is likely that positive harm 
is done by lowering the vitality of the superficial cells. 



THE, METHOD OF REVERDIN" 



25 



Certainly no benefit can result from irrigating with anti- 
septics after transplantation, as has been suggested. 

As soon as the grafts are cut, they are placed at once, by 
means of forceps or needle, upon the surface to be grafted, 
with their raw sides down (Figs. 5 and 6). Edges which 
have a tendency to curl under are carefully unfurled by 
pressing upon the bit of skin with a probe and shoving it 







Fig. 6. — (I) Reverdin graft in place at the end of planting; (II) Sixteen 
days later (Ehrenfreid and Cotton). (From Boston Med. and Surg. Jour- 
nal, Vol. CEXI, No. 26, 1909.) 

carefully from side to side. Adhesion to the granulations 
immediately takes place, especially if no blood or other 
fluid be present, slight pressure with a moist pledget of 
gauze assisting the process. Roberts and others claim that 
exposure of the ulcer to the atmosphere for a time before 
and after operating causes the surface to become sticky and 
facilitates adherence, but this can seldom be required. It 
is unnecessary to fasten the grafts in place with fine sutures 
(Hueter), or to bury them beneath a trap-door in the gran- 



26 SKIN GRAFTING 

illations, as was advocated by Eorth, 16 Dunn, 17 and 
others. 

Each graft is capable of enlarging to but a limited extent, 
perhaps the size of a silver dime, and it cannot stimulate 
the borders of the ulcer effectually at a greater distance 
than half an inch. If a single graft is placed in the center 
of a sufficiently large ulcer, it will produce an island of 
skin only, and in addition it does not seem to grow so well. 

Hence the transplanted pieces should not be farther 
apart than half an inch, and better closer than this. They 
should also not be at a greater distance from the edges of 
the ulcer. 

If the grafts are sufficiently close together, there is no 
object in placing them in regular rows or geometrical 
figures. Should the number be limited, it is wiser to thor- 
oughly cover a comparatively small area than to scatter 
the material over too extensive a surface. The use of 
scarlet-red ointment may hasten epithelial formation over 
the remainder of the ulcer, 1S but it should not come in 
contact with the grafts. 

Legal Questions. 

Legal complications have arisen from skin grafting in 
one or two instances at least. One of these occurred in 
Atlanta. A boy, thirteen years old, brought his little 
cousin to a physician's office, with an affection requiring 
the transplantation of skin. The boy willingly consented 
to have the grafts removed from his own arm, which was 
accordingly done. The father immediately brought suit 

16 Med. Rec, Jan. 9, 1886, p. 36. 

17 St. Louis Med. and Surg. Journal, July, 1895. 

18 Von Schmieden, Zentralbl. f. Chir., 1908, p. 153. 



THE METHOD OF KEIVEBIHN" 



27 



upon the grounds that the action was unjustifiable and 
brutal, and that he had not been consulted. The case was 
promptly decided for the defendant, as was also another 
in Cincinnati, in which a man who was paid to furnish 
grafts claimed that too much skin had been taken and 
sued the surgeon for damages. 

Dressings. 

Some sort of dressing should be employed for the sake 
of protection from dirt and accident, not, however, because 
a dressing is essential to the vitality of the grafts, which 
will thrive just as well when enclosed in some box-like 




Fig. 7. — ■ Strip of rubber tissue Avith punched-out drainage holes 



covering, or when not covered at all 19 (see chapter on 
Thiersch Grafting). 

It is usually recommended to place rubber protective 
next the grafts to prevent their adherence and displace- 
ment- when the dressings are changed. This should be 
cut into strips, perhaps half an inch in width, which are 
placed side by side, or criss-crossed, like basket-work, or 
punched full of holes, in order to furnish exit for the secre- 
tions (Fig. 7). Strips of transparent sheet gutta-percha 
may be used, and their ends allowed to project on the 
sound skin, where they will adhere if moistened with a 

19 Yemans — Leonard's Med. Jour., 1888. 



28 SKIN GRAFTING 

little chloroform. If more convenient, there is no ob- 
jection to the employment of goldbeater's skin, oiled silk, 
isinglass plaster, tin or silver foil, etc. Marcy 20 prefers 
to use ordinary adhesive plaster, which may often succeed 
on the principle that epithelium will grow in spite of al- 
most anything. 

All of these methods possess the disadvantage of caus- 
ing more or less maceration which may jeopardize the 
vitality of the new skin. A preferable and much simpler 
device consists in spreading a single layer of gauze over 
the grafted surface and pinning it around the limb, or 




Fig. 8. — Strip of gauze pinned about leg for holding grafts in place. 

fastening it to the skin in a number of places with collodion 
(Fig. 8). This was suggested by McCarthy, 21 and later 
independently by the writer. 22 Bidwell 23 uses gauze of 
spun glass, which would seem to be an ideal material for 
the purpose. The meshes of the specially prepared netting 
employed by Davis are so wide that it is more suitable for 
"splinting" large Thiersch grafts than for holding in place 
the small pieces of epithelium under consideration (see p. 
51). While the superjacent dressings are changed, the 
gauze remains permanently in place until healing is com- 
plete. Absorption of the discharge is thus permitted, and 

20 Med. Rec, Aug. 18, 1894. 

21 Med. Press and Circ, Apr. 13, 1881, p. 311. 
23 Cincinnati Lancet-Clinic, 1885. 

23 Lancet, July 21, 1894, p. 130. 



THE. METHOD OF REVERm^ 29 

the condition of the grafts is easily ascertained at any time 
without disturbing them. 

Bryant insisted upon the use of a separate piece of lint 
over each graft, but. this is perhaps more troublesome than 
advantageous. 

Wet and Dry Dressings. 

Whether the main dressing is dry or moist is usually 
of little importance, but no powerful antiseptic should be 
employed. It is customary to dust various non-irritating 
powders over the grafted surface, such as iodoform, boric 
acid, acetanilid, aristol, etc., but their value is question- 
able, simple sterile gauze often being equally serviceable. 
If a powder is used, care must be taken that it does not 
form a crust, beneath which pus may accumulate and de- 
stroy the grafts. 

If the operator prefer, an ointment containing any of 
the powders mentioned above will give good results if the 
discharge is not excessive. Scarlet-red ointment (see p. 
56) may be useful in hastening the epithelialization of 
uncovered portions of a granulating surface, but it should 
not come into contact with the grafts themselves, at least 
until they have become firmly adherent, for fear of causing 
their destruction. 

Bovinine has often been employed — so-called ''grafting 
in blood" — with the idea that additional nutrition is thus 
furnished to the grafts during the process of adhesion, but 
the utility of the method is somewhat questionable. The 
material may be spread upon the grafted surface like but- 
ter upon bread. 

A pad of gauze covered with cotton completes the dress- 



30 SKIN" GRAFTING 

ing, which is held in place under moderate pressure with 
a bandage. 

In case a wet dressing is chosen, the powder or salve is 
omitted, a pad of gauze wrung out of warm normal salt 
solution or boric acid being used instead. An outside cov- 
ering of oiled silk will prevent too rapid evaporation and 
render moistening of the dressings unnecessary oftener 
than perhaps once in twenty-four hours. 

Changing Dressings. 

If the field of operation were always aseptic, it would 
be unnecessary to change the dressings at all during the 
process of healing; but unfortunately this can seldom be 
the case, as a certain amount of suppuration is nearly al- 
ways present. It is, therefore, desirable to remove all 
but the lowermost layer of gauze, or protective, as the case 
may be, every twenty-four to forty-eight hours, prolonged 
soaking in warm salt solution being necessary when the 
dressings have a tendency to stick. Gentle irrigation is 
then in place, although the surface must not be rubbed for 
fear of displacing the transplanted cuticle. 

AVhen there is considerable discharge, and protective has 
been used, it should frequently be changed as well as the re- 
mainder of the dressing; but when the discharge is not 
great, it can often be left in place for from five to ten days. 

It is difficult to avoid a certain amount of musty or even 
more offensive odor, and at times the dressings become 
green in color from the presence of Bacillus pyocyaneus; 
but success is not often seriously jeopardized by these 
occurrences. 

Instead of employing dressings of various kinds, the 



THE METHOD OF REIVEBDIN 31 

"open method" may be used, as is often done in Thiersch 
grafting, the grafts being directly and freely exposed to 
the air beneath a protecting wire-gauze cage (see p. 49). 
The presence of much discharge, hoivever, is apt to render 
the procedure unsatisfactory, owing to the formation of 
thick crusts. 

When grafting is done near a joint, particularly in chil- 
dren, some form of splint should be applied to prevent 
motion of the part. The lower extremity, especially where 
varicose veins exist, should be elevated in order to favor 
circulation. 

Process of Healing. 

In the course of twenty-four hours the grafts seem to 
swell, appearing whiter, thicker, and softer ; and in two or 
three days those which have "taken" become pinkish in 
color with a reddish areola. Then a thin, pearl-gray 
epithelial pellicle begins to grow out from their borders 
and from the adjacent edges of the ulcer, like ice from 
the shores of a pond. The bits of skin which turn brown 
are probably dead, while those which are yellowish white 
will lose their superficial layers of epidermis at least. 
This exfoliation of epidermis is common and usually occurs 
in three to five days. It does not mean that the grafting 
has failed, as the deeper layers remain, and that which 
has been lost is soon reproduced. 

The new epithelial pellicle is not attached to the granula- 
tions at first, but rests like fine tissue-paper upon their 
flattened surfaces, from which it may easily be lifted, and 
perhaps utilized for further grafting (see p. 23). Soon 
long fine processes or "roots" grow down into the granula- 



32 SKIN GKRAFTTNG 

tions, anchoring the epithelium, and "bridges" are often 
thrown out, connecting the grafts with each other or with 
the borders of the ulcer. 

After-treatment. 

When cicatrization is complete, the part must be pre- 
served from injury for several weeks, until a certain 
amount of resisting power has been attained ; for ulcers 
cured by the Reverdin method, especially those of the 
lower extremities, are prone to break down on slight provo- 
cation. If there is a tendency to dryness and exfoliation, 
an ointment should be used containing some unirritating 
substance, such as boric acid. 

The new skin is not by any means equal to ordinary skin, 
although it is much better than mere cicatricial tissue. It 
contains no hair bulbs, sweat glands, or sebaceous follicles. 
The grafts regain a certain amount of sensation in the 
course of time, although it is often imperfect and long in 
making its appearance, slowly progressing inward from the 
periphery. 



CHAPTER IV 

THE METHOD OF THIERSCH— ITS USE IN" 
SPECIAL CASES 

There is no process of skin grafting so simple, so re- 
liable, and so generally applicable as the method of 
Thiersch, 1 and yet it has never received the thorough recog- 
nition to which it is entitled. Granulating surfaces or 
fresh wounds of almost any extent may be covered with 
epithelium in from ten days to three weeks ; embarrassing 
cicatricial contractions are avoided ; and the prevention of 
suppuration and other septic processes may be instru- 
mental in saving life or limb, to say nothing of shortening 
the period of convalescence. In many cases the cosmetic 
value can scarcely be overestimated. 2 

General Technic. 

If a suppurating area is to be grafted, the adjacent skin 
should be scrubbed, all crusts and hairs removed, and the 
surface on which the grafts are to lie irrigated with normal 
salt solution. The patient is anesthetized, and the granula- 
tions are then scraped away with a spoon down to the 
comparatively firm tissue beneath, which is sometimes 
suprisingly deep. Oozing is checked by pressure and by 

1 XV. Kong. deut. Gesell. f. Chir., Berlin, 1886. 

2 As regards priority, Oilier (Bull, de l'acad. de Med., 1872) was in the 
habit of cutting grafts 10 to 15 mm. wide and 2 to 4 cm. long, resembling 
in every way Thiersch grafts ; but unlike Thiersch, he did not scrape away 
the granulations before making the transplantation. Fischer (Zeit. f. Chir. 
Bd. 13, 1880, p. 193) also shaved from the surface of a limb, thin strips of 
skin identical with those used by Thiersch. 

33 



34 



SKIN" GEAFTING 



elevation, where practicable. After removing the blood 
and debris with warm salt solution, the surface is ready 
for the grafts. 

These are best obtained from the anterior surface of the 
thigh and are conveniently cut with a sharp razor. An 
assistant makes the surface as tense as possible by means 
of a hand on either side of the limb, or by grasping the 
thigh from below, while the operator, standing with his 




Fig. 9. — ■ Cutting- Thiersch grafts from thigh. 

back to the patient's feet, cuts toward himself, with his left- 
hand stretching the skin in front of the razor in the direc- 
tion of the knee (Fig. 9). Pieces of gauze beneath the 
hands will prevent them from slipping. With a side- 
to-side sawing motion it is not hard to remove thin shav- 
ings of epidermis, from half an inch to an inch or more 
in width and several inches in length, the manipulation 
being easier with firm skins than with flabby ones, and 



THE METHOD OF THIERSCH 



35 



rather difficult with the thin cuticle of young children and 
old people. Both skin and razor should be kept wet with 
salt solution. 

It is -neither necessary nor desirable to remove the entire 
thickness of the skin, but simply a paper-like layer, leaving 
a number of bleeding points from division of capillary ves- 
sels in the ends of the papillae. Although the procedure 




Fig. 10. — Thiersch graft partially cut — note position of assistant's hands on 
each side of thigh, with gauze pads to prevent slipping. 



is simple enough, it should be practiced upon the cadaver 
before being tried upon the living. 

The delicate strips of skin fold up on the razor as they 
are cut (Fig. 10), and as soon as a sufficient length has been 
obtained, a slight inclination of the instrument away from 
the thigh will readily sever the graft from its connections. 
- The grafts are then spread smoothly upon the area to be 
covered, so that they overlap each other shingle-wise, and 



36 



SKIN GRAFTING 



also overlap the edges of the Wound, completely concealing 
the raw surface (Figs. 11 and 12). When the sections are 



ife 



Fig. 11. — Showing how Thiersch grafts should overlap each other and the bor- 
ders of the ulcer. 

large, they may advantageously be "buttonholed" with a 
pair of scissors or extensively perforated with a punch 




Fig. 12. — Thiersch grafts in place — granulating wound of buttock. 

in order to facilitate drainage (Davis). If too much skin 
has been obtained, the redundant portions may be replaced 



THE! METHOD OF THIERSCH 37 

upon the raw surface from which they were removed, where 
they will readily adhere. 

Hemorrhage. 

In order to control hemorrhage which may follow the 
curetting, Thiersch at first employed an Esmarch strap, 
leaving it in place until the grafts and dressings had been 
applied, but he afterward discarded the procedure as being 
unnecessary and possibly harmful. Others, however, have 
taken up the idea, thinking, perhaps, that it was new, and 
have used it extensively. In general, there is little objec- 
tion to the employment of the strap, and it is at times of 
advantage, although following its removal undesirable 
oozing may take place beneath the transplanted skin. 

There seems to be no reason for agreeing with Fischer, 
who says that skin will grow better when removed from a 
bloodless part and applied to one equally bloodless, a view 
curiously at variance with the ideas of those who advocate 
irritation and congestion of the skin before grafting. 

Pressure with moist pledgets of gauze, perhaps saturated 
with peroxid of hydrogen or a solution of adrenalin, nearly 
always controls bleeding in a few moments, especially if 
the part be elevated and the pressure applied over a piece 
of rubber protective, in order to prevent tearing the clots 
from the mouths of the small vessels when the compressing 
material is removed. An effective method is to apply a 
thin rubber bandage around the limb or body and directly 
over the raw and oozing surface. Kushmore 3 advocated 
the use of a high-frequency electric current for the purpose 
of coagulating the blood and causing the grafts to adhere. 

3 Ann. Surg., 1904, Vol. 40, $>. 404. 



38 SKIN GKAFTING 

but this is of doubtful advantage and has never been ex- 
tensively adopted. It is much better to twist a vessel than 
to tie it, as ligatures are prejudicial to success. The sur- 
face should be rendered as "dry" as possible, in order to 
favor adhesion and growth of the new cuticle. 

Curetting. 

With Thiersch, the removal of granulations was one of 
the principal features of his original method. He claimed 
that the more or less large and soft, superficial granula- 
tions, during their slow transformation into connective tis- 
sue, were the cause of cicatricial contraction, and that this 
contraction could be avoided by scraping away the granula- 
tions until firmer tissue was reached. He also thought that 
grafts grew better when this was done. This advice was 
universally followed until it was demonstrated by Schnitz- 
ler and Ewald 4 that it is unnecessary to remove healthy 
granulations and that grafting can be done directly upon 
their unaltered surfaces with the production of a movable 
skin, and without appreciable subsequent contraction. It 
should be mentioned, however, that numerous operators 
have been unable to obtain reliable results without curet- 
ting, and it will certainly always be in place where it is 
desirable to remove unhealthy granulations or diseased 
tissues. In any case, the results are probably more univer- 
sally satisfactory, when the granulations are removed. 

It has been claimed that where scraping is not resorted to 
an anesthetic, either local or general, is unnecessary, because 
of the comparatively slight burning pain produced by the 
cutting of the grafts, which is said to be made still less by 

4 Cent. f. Chir., No. 7, 1894, p. 148. 



THE METHOD OF THIERSCH 39 

the use of the- Esmarch strap. These statements, however, 
by no means always hold good, the pain being often quite 
severe. 

Instead of scraping with a curette, Sick 5 simply rubs 
away the granulations with a bunch of gauze, or a stiff 
nail-brush may be used. Halsted, McBurney, and others 
prefer to shave the surface with a scalpel or an amputating 
knife, claiming that a smoother surface is obtained devoid 
of partially separated and bruised portions of tissue, which 
tend to become necrotic and interfere with the vitality of 
the transplanted skin. 

Warm salt solution, upon which Thiersch has laid so 
much stress, is to be recommended for irrigation, but it is 
not necessary, as ordinary sterilized water answers almost 
the same purpose, both during the operation and subse- 
quently. A four per cent solution of boric acid can also be 
used if desired. Thiersch and many others speak de- 
cidedly against the employment of antiseptics after the 
curetting, has been done, claiming that the superficial 
necrosis thus produced interferes materially with the ad- 
herence of grafts; but there is no doubt that strong anti- 
septics may be freely employed both before and after 
curetting, 6 providing they are subsequently washed away 
with some neutral solution. Their utility, however, is 
questionable, as asepsis cannot thus be obtained. 

Preparation of Granulations. 

Granulating surfaces should be prepared with even 
greater care in Thiersch grafting than in the method of 
Eeverdin. (See chapter on The Method of Eeverdin.) 

5 Arch. f. Klin. Chir., Bd. 43, p. 387. 

G C Hiibscher, Beitr. z. Klin. Chir. Bd. 4, 1888, p. 395. 



40 SKIN GRAFTING 

When considered advisable, the procedure of Wilcox may 
be used : 7 The evening before the operation, the part is 
thoroughly cleansed with green soap and hydrogen per- 
oxid and put up in a compress wet with 1 per cent 
formaldehyde (the ordinary 40 per cent solution being 
taken as the unit), which is left on over night. The gran- 
ulations, tendered dark, red, and dry, are then scraped 
away down to the firm vascular tissues beneath, an Esmarch 
bandage being wound directly over the raw surface, when 
possible, in order to control oozing by means of pressure, 
the rubber having no tendency to stick when removed. 

Davis 8 recommends cleansing and drying the ulcerated 
surface on the previous day, painting it with tincture of 
iodin, and then dressing it with balsam of Pern (2 to 6), 
which is allowed to remain until the operation, when it is 
washed away with normal salt solution. 

These methods are said to have the advantage of render- 
ing the part aseptic, and they probably do so, in the ma- 
jority of instances at least ; but they are seldom necessary. 

Methods of Cutting Grafts. 

The grafts may be removed from any convenient portion 
of the body, the anterior surface of the thigh being nsually 
chosen, although Franke prefers the outer side, as it can 
be made tense by adducting the limb. Davis claims that 
grafts should always be obtained from the right thigh when 
possible, because phlebitis is more apt to follow when the 
left limb is employed, but this somewhat theoretical as- 
sumption is generally disregarded in practice. 

McBurney stretched the skin between two "hooks" sup- 

7 Ann. Surg., May, 1904. 

8 Ann. Surg., Dec. 1910, p. 721. 



THE METHOD OF THIERSCH 41 

plied with teeth, which catch the skin transversely to the 
long axis of the limb. (Fig. 13.) Mixter 9 employed an 
instrument consisting of an oblong fenestrated steel plate 
with several short, sharp pins projecting from its slightly 
concave surface to prevent slipping. When this is pressed 
firmly against the thigh, the skin projects through the 
fenestrum and may be flattened with a roller and shaved 
off with a specially constructed knife. 




Fig. 13. — McBurney's hooks for stretching skin. 

Some operators prefer razors which are flat on one side, 
and others use an amputating knife, a small scalpel, or the 
blade of a microtome ; but there is really nothing more con- 
venient than an ordinary sharp razor. The complicated 
apparatus of Mixter is not necessary, although it produces 
strips of skin with smooth edges ; but this can be accom- 
plished, if desirable, by outlining the graft with a scalpel 
before shaving it off. A safety razor can sometimes be em- 
ployed to advantage. 10 Whatever instrument is used, its 

9 Boston Med. & Surg. Jour., Dec. 31, 1891. p. 700. 
"Doolittle, J. A. M. A., Mar. 26, 1898, p. 716. 



42 



SKIN GRAFTING 



blade should be kept moist with salt solution, or with a 
mixture of glycerin 25 parts, alcohol 25 parts, and water 
50' parts. 11 

Halsted, of Johns Hopkins, 12 employs very large grafts, 
especially following operations for cancer of the breast. 




Fig. 14. — Halsted method of cutting large Thiersch grafts. (From Johns 
Hopkins Hospital Reports, Vol. XV, p. 316.) 

In cutting them, he places a sand-bag beneath the thigh, 
so as to give a broader surface, and stretches the skin be- 
tween two small boards, like shingles, held crosswise to 
the limb, with their edges pressed firmly against the sur- 

11 E. Barker, Practitioner, Oct., 1888. 
12 Ann. Surg., 1909, Vol. 50, p. 542. 



THE METHOD OF THIERSCH 43 

face. One of these boards is pulled upward by an as- 
sistant, while the other is pulled downward by one hand 
of the operator (Fig. 14). An amputating knife is used 
to sever the grafts, which are spread raw side upward on 
rubber protective or silver-foil, upon the surface of a board, 
before transferring them, together with the protective, to 
the wound. The procedure requires some technical skill. 
There is no danger of the subsequent development of 
hairs in the transplanted cuticle, as has been affirmed by 
Thompson, because in Thiersch grafting the bulbs are left 
behind. It is desirable, however, to shave the part to 
prevent the severed hairs from getting beneath the grafts 
and interfering with their union. The skin should be 
surgically clean, as in any other operation. 

Placing the Grafts, Etc. 

The strips of epidermis are so thin that they fold up 
on the razor and may be carried directly to the surface 
to be grafted without first floating them out in water and 
transferring them upon a spatula or piece of glass, as is 
often done. The edge, of the razor with its folded graft 
is placed near the border of the ulcer, and the end of the 
graft slid from the blade and held by a probe against the 
skin (Figs. 15 and 16). The razor is then slowly moved 
across the ulcer, spreading out the strip much as a nurse 
spreads a sheet beneath a patient. The edges, which are 
often more or less turned under, must be carefully un- 
furled by sliding the grafts back and forth with a probe. 
The new skin should be gently pressed in place with a 
pledget of moist gauze in order to promote adhesion and 
disperse air-bubbles and blood. 



44 



SKIN GRAFTING 



Jungengel has shown that if a layer of clot be present 
beneath the grafts which is a little too thick the outer layers 
of epithelium are apt to exfoliate, and if very much coag- 
ulated blood exists, the entire graft may perish. It has 
been said that a certain amount of clot is of value in that 
it promotes nutrition and prevents suppuration, but this 
statement has not been confirmed. 

Some surgeons prefer to cut at once all the grafts they 




Fig. 15. — Sliding Thiersch graft from razor on to surface of ulcer. 

expect to use, placing them in warm salt solution. An as- 
sistant then spreads them raw side up on strips of sterile 
protective or on moist toilet-paper, by means of which they 
are transferred to the field of operation, the protective re- 
maining in place as the first layer of the dressing. This 
has its advantages where, owing to the locality to be 
grafted, the simpler method already mentioned cannot be 
employed. McNaught rolls the strips of skin upon a 
probe, by means of which they may easily be transported 
and accurately adjusted; or they can be spread upon a 



THE METHOD OF THIERSCH 



45 



sponge and applied as a goldbeater applies gold leaf (Bruce 
Clarke). 

If the grafts are large, they should be perforated at fre- 
quent intervals in order to provide means of exit for fluids, 
which might otherwise accumulate beneath them and 
cause their disintegration by separating them from the 
underlying surface. This can be accomplished after the 




Fig. 16. — Placing Thiersch grafts from razor — granulating wound of buttock. 



grafts are in place by snipping out small pieces with a pair 
of curved scissors, or the - grafts may first be spread on 
strips of rubber protective and perforated with a punch or 
with scissors. 13 This seems like an excellent method, but 
Yogel claims that when it is used it is desirable to employ 
a moist dressing for several days to prevent closure of the 
openings by dried secretions. 

13 Davis, Internat. J. Surg., May, 1910. 



46 SKIN" GRAFTING 

Grafting in Two Stages. 

Wentscher 14 and Porter advocate the performance of 
Thiersch grafting in two stages, at least in certain cases, 
especially where bleeding cannot be promptly checked. 
At the first sitting, they scrape the nicer and cnt the neces- 
sary grafts, putting them in salt solution at room-tempera- 
ture, where they may be kept without injury for many 
hours. At a second sitting, the new skin is placed in posi- 
tion, no anesthetic being required. In this connection, it 
is interesting to note that Lynngren has successfully grafted 
pieces of epithelium kept for three months in sterile ascitic 
fluid, and that dried epidermis has "taken" after as long 
as 418 days. 

Thin vs. Thick Grafts. 

There is some difference of opinion as to whether it is 
desirable to use thin grafts or thick ones, some going so 
far as to recommend the employment of the entire thick- 
ness of the skin (Fowler, Moullin, Cheyne, etc.). When 
this is done, however, it is better to dissect out the grafts 
and suture the resulting wound according to the method 
of Wolfe. Fowler 15 contends that more than the papillae 
should be removed with the razor, but that no fat should 
be included, the idea being to obtain the stroma con- 
taining the horizontal network of vessels. Kellock 16 
suggests a sort of combination of Wolfe grafts with 
Thiersch grafts, cutting them so that the whole thickness 
of the skin remains in the center surrounded by a thinner 

"Berl. Klin. Woch., No. 43, 1894. 

15 Ann. Surg., 1889, p. 179. 

16 Lancet, Nov. 25, 1899. 



THE METHOD OF THIERSCH 47 

area, the latter being shaved off first. The technic, how- 
ever, is complicated and has not been generally adopted, al- 
though Porter strongly recommends it in grafting areas 
from which x-ray burns have been excised from the hands 
(see Grafting in X-ray Burns). 

It is perhaps well to avoid grafts of exceeding thinness ; 
but nevertheless, when moderately thin ones are placed by 
the side of those which are quite thick, the former seem 
to be as satisfactory for most purposes as the latter'. In 
general, a good graft may be said to be but little thicker 
than the paper upon which this is printed. 

Little or no scar results from the removal of these thin 
slices of epithelium, at most a thin, white, almost imper- 
ceptible cicatrix, although the seat of the operation remains 
brownish in color for weeks. Different sets of grafts may 
be removed from the same area, providing sufficient time 
elapses between the operations to allow a new growth of 
epithelium to occur. 

Anesthetics. 

It has been claimed that a general anesthetic, especially 
ether, was detrimental to the vitality of grafts, and pa- 
tients have been needlessly tortured on this account. Ex- 
perience has' demonstrated that a, general anesthetic has no 
appreciable effect upon the transplanted skin, and the 
operation is often sufficiently painful to justify its em- 
ployment, in spite of the statements of Fowler, Plessing, 
and others to the contrary. (See chapter on Local Anes- 
thesia in Skin Grafting. ) 



48 SKIN GRAFTING 

Dressings. 

It has been abundantly demonstrated that it is unneces- 
sary to keep the grafts moist as emphasized by Thiersch ; 
in fact, they seem to do better in many cases when the 
dressing is a dry one — simply a sprinkling of iodoform 
or boric acid and a covering of gauze and cotton, as in 
the treatment of ordinary wounds, and there is really no 
great need for a powder at all. There are those, however, 
who speak against a dry dressing, claiming that the desic- 
cated secretions interfere with the escape of fluids between 
the grafts, which accordingly accumulate and elevate the 
new skin at various points, thus leading to its destruction. 
Moderate pressure is beneficial, but too tight bandaging 
may cause sloughing. 

If a moist dressing is preferred, it is unnecessary to 
change it, if a heavy one and protected by oiled silk, 
oftener than every day or two, as has been shoAvn by Mc- 
Burney, Halsted, and others ; although Thiersch contended 
that a fresh dressing must be applied every two hours, 
or the old one moistened at least. 

A sterilized non-irritating ointment of some kind (boric 
acid, iodoform, etc.) makes a satisfactory dressing and 
is used by some, while others prefer bovinine, from the 
somewhat questionable idea that it furnishes nutriment to 
the grafts prior to their firm adhesion. Instead of salt 
solution, the layers of gauze may be moistened with steri- 
lized olive oil, which will not require such frequent re- 
newal, or with a 4 per cent solution of boric acid. Dun- 
ham 17 thinks it advisable to remove a moist dressing at 

17 Ref. Handb. Med. Sci., Supplement. 



THE METHOD OF THIERSCH 



49 



the end of six days and allow the grafts to become dry, 
claiming that they are thus rendered tougher. 

Strips of rubber protective, silver foil, tin foil, gold- 
beater's skin, etc., are ordinarily used next the grafts, or 
simply a layer of gauze, as described on page 28. Other 



.•£11111 


: If »? i 




- 


\ 

I 




i 1 


: jssa 


8 







Fig. 17. — Wire cage in place in open method of grafting — side view. 
(From International Journal Surgery, May, 1910.) 

successful methods of dressing have been suggested, in 
one of which everything is lifted clear of the new skin by 
means of small strips of board elevated on cushions of 
cotton; or "cages" made of wire gauze may be employed, 
their rough edges being bound with adhesive plaster — the 
"strainers" used in kitchens are convenient (Figs. 17, 18, 
and 19). 



50 



SKIN GRAFTING 




Fig. 18. — Wire cage in place in ' ' open method ' ' of grafting — front view. 




Fig. 19. — Wire cage for open method of grafting — edge bound with adhesive 

plaster. 



THE METHOD OF THIERSCH 51 

Much has heen claimed for this "open method/' and 
it certainly gives excellent results, sometimes succeeding 
where other procedures fail. Goldmann 18 emphasizes the 
point that the primary fixation of the grafts, which takes 
place by filbroblasts and capillaries in from 12 to 24 hours, 
is the most important thing, This, he says, is best accom- 
plished by the open method, and after it has once occurred, 
the further character of the dressing, whether dry or moist 
or by means of ointments, is of little significance. 

A "dry cage" can be converted into a "moist chamber" 
by covering it with wet gauze, or salt solution can be 
dropped directly upon the grafts from an irrigator; but 
there would seem to be nothing gained by this. 

' 'Splinting" Grafts. 

Davis 18a holds down or "splints" the grafts with curtain 
netting, having a mesh of about % of an inch (Fig. 20). 
In order to give the material stability, he soaks it in 30 
parts of gutta-percha dissolved in 150 parts of chloroform. 
It can be sterilized by placing it between layers of gauze, 
and treating it for 36 hours in 1 :1000 bichlorid, changing 
the fluid every 12 hours. It can then be kept permanently 
in this solution, which must, however, be thoroughly rinsed 
away before the material is used. Book-muslin impreg- 
nated with varnish may also be used, or silk netting treated 
with paraffin. 19 In employing these "'splints," they must 
overlap the sound skin, and may remain in place from 4 
to 10 days, the overlying dressings being meanwhile 
changed as often as may seem necessary. 

18 Zentralb. f. Chir., p. 793, 1906. 

18 a Am.. Surg., 1909, p. 416. 

19 Parry, Am. J. Surg., July, 1909, p. 243. 



52 



SKIN GRAFTING 



Bernhard 20 advocates exposure of the newly grafted 
area for a short time to the direct rays of the sun; while 
Schepelmann 21 douches the new skin for several weeks 
with hot air, by means of a special electric instrument, 




Fig. 20. — Method of "splinting" grafts with rubber-impregnated curtain- 
netting (Davis). (From Johns Hopkins Hospital Bulletin, XXI, p. 41.) 

claiming that better and more permanent results are thus 
obtained. 

Thies 22 covers the grafts with a thick layer of fine sand, 
which has been sterilized by boiling in a 1 per cent solution 
of sodium carbonate and then dried. He considers that 

20 Deut. Zeitschr. f. Chir., 1905, B. 78, p. 574. 

21 Med. Klinik, 1911, p. 1048. 

22 Zent. f. Chir., 1911, p. 458. 



THE MEITHOD* OF THIERSCH 53 

this method has a number of advantages, among which are 
the removal of fluids by capillary suction, the splinting of 
the grafts, and the prevention of coagulation of the dis- 
charges by the alkalinity of the material. The sand should 
be changed frequently. 

If the grafted surface is near a joint, it is best to prevent 
movement by means of an ordinary splint. It is well to 
examine the transplanted skin, especially if about the face, 
in 24 hours, in order to make sure that nothing has slipped 
because of vomiting, etc. If everything is in place at 
that time, it will remain so. If a graft has become dis- 
placed, it is best to remove it and apply another at once, 
which can usually be done under local anesthesia with but 
little inconvenience to the patient. 

Treatment of Wounds After Removal of Grafts. 

The raw and slightly bleeding surface of the thigh, from 
which the grafts have been taken, can be dressed as one 
would dress an ordinary wound. McBurney, however, 
prefers a covering of gauze moistened with normal salt 
solution, believing that healing will thus take place more 
readily and with less pain; but others have been unable to 
notice a difference in this respect. An excellent method 
is to use sterile boric acid ointment and rubber protective, 
thus avoiding drying and sticking of the dressing, which 
causes considerable discomfort. Frequent changing of 
such -a dressing is unnecessary. 

Much more pain is usually felt in the thigh than in the 
part to which the grafts have been applied ; in fact, even 
when considerable pain is present in an ulcer, it is apt to 
cease when transplantation has been done. 



54 



SKIN" GRAFTING 



"Accordion Grafts." 

Lanz 23 has suggested a method by which the wound 
from which the grafts were obtained can immediately be re- 
covered. This is accomplished by shaving off a large 
Thiersch graft and stamping slits in it with an appropriate 




FIG.3 

Fig. 21. — " Accordion grafts " (Lanz). (From Zentrabl. f. Chir., 1908, p. 3.) 

die, so that it may be drawn out, like an accordion, to 
twice its original length (Fig. 21). It is then divided, 
one half being used to cover the wound from which the 
graft was cut, while the other half is placed on the sur- 
face to be grafted. This ingenious procedure should be 
of much service — by shortening the tedious healing of a 
large raw surface, by promoting drainage, and by furnish- 

23 Zentralbl. f. Chir., 1908, p. 3. 



THE: METHOD OF THIERSCH 55 

ing a means of obtaining more material in cases where 
the surface to be grafted is large and the available skin 
small in amonnt. Under local anesthesia the extent of the 
operation will also be lessened — a point of some importance 
to the patient. Such grafts should be "splinted" firmly 
in place by gauze or by netting (see p. 51). Instead of 
using a specially made die, the grafts may be spread upon 
a sterile board and nicked with a sharp knife. 

Proper Time for Grafting. 

There is no reason -for deferring skin grafting until 
granulation has set in, as is habitually done by some, as 
the grafts take just as well or better when applied to fresh 
wounds, thus saving the patient the considerable annoy- 
ance, not to say danger, of a second anesthetization. If, 
for instance, an operation is to be done in which the wound 
will be too large to permit approximation of the edges, as 
in cancer of the breast, a thigh is sterilized and wrapped 
in a surgically clean towel. As soon as the major opera- 
tion is completed, the grafts may be cut, immediately put 
in place, and an ordinary dry dressing applied, the entire 
procedure occupying but a few minutes. 

When granulation has once begun, it is well to wait until 
the process has become thoroughly established and all 
sloughing tissue has disappeared, which, according to 
Thiersch, and others, requires five or six weeks ; but this is 
unnecessarily long, two or three weeks usually being suf- 
ficient. 

It is important that the granulations should be in good 
condition, especially if the operation is to be done without 
scraping. It is sometimes possible, however, to graft un- 



56 SKIN GRAFTING 

healthy ulcers, and Kraske has succeeded in covering the 
ulcerating surfaces of malignant tumors, although the new 
skin is apt soon to disappear. Better results are, of course, 
obtained when the conditions are more nearly normal, a 
favorable sign being the appearance of a pellicle of new 
skin at the borders of the ulcer. 

After-treatment. 

From seven to ten days are required for grafts to become 
firmly fixed; and unless suppuration or some other acci- 
dent occurs, the lowermost layer of gauze or protective may 
be left in place for two weeks. To avoid danger of loosen- 
ing the delicate adhesions of the new skin, the coverings 
should be soaked off with warm salt solution ; although 
occasionally, when healing has been perfect and dry dress- 
ings have been employed, they slide off as though no defect 
in the skin had been present. 

Some mild ointment should subsequently be used to pre- 
vent dryness and cracking of the tender epithelium, which 
must be guarded from injury or sudden changes of temper- 
ature for several weeks. Particularly is this true of crural 
ulcers and those which have a tendency to reappear after 
grafting. 

It often happens, especially under moist dressings, that 
the outer layers of epidermis die and become macerated, 
so that when the dressing is removed the grafts apparently 
come away with it, leaving a grayish, sodden surface be- 
hind. This does not necessarily mean failure, for in a 
few days the epithelium will generally be replaced from 
the remaining rete Malpighii. 






THE METHOD OF THIERSCH - 57 

Schmieden 24 claims that scarlet-red ointment stimulates 
the growth of epithelium to a remarkable degree, and this 
opinion has been confirmed by many others. The method 
may be used to advantage in Thiersch grafting where for 
some reason the entire area has not been covered by skin, 
but care should be taken that the ointment should not come 
in unnecessary contact with the grafts, especially before 
they have become firmly adherent, as it might cause their 
destruction. 

Application of Thiersch Grafting. 

It is astonishing to what useful purposes Thiersch 
grafting may be applied in the treatment of various lesions 
— such as old ulcers, including the intractable crural ulcer, 
fresh wounds with loss of skin, defects remaining after 
plastic operations, or after the removal of tumors, nevi, 
cicatrices, etc., and extensive bums, especially where sub- 
sequent contractions are feared. Debilitating suppurative 
and septic processes may be checked by this means, and 
sometimes life saved. Amputation may occasionally be 
avoided. The offensive ulcerating surfaces of inoperable, 
malignant tumors may be skinned over, as demonstrated 
by Kraske. Tuberculous affections of the skin may be cut 
and scraped away, and the defects filled in with Thiersch 
grafts. Flat nevi may at times be shaved off and re- 
placed by new skin, causing comparatively slight disfigure- 
ment: Even obstinate cases of lupus erythematosus have 
been successfully treated in this manner. The grafts will 
adhere to periosteum, to bone from which the external sur- 
face has been removed, to tendons, fascia, dura mater, 
muscle, etc., and mucous surfaces may also be grafted — -for 

^Centralbl. f. Chir., 1908, p. 153. 



58 SKIN GRAFTING 

instance, the vagina, either with sections of mucosa, or with 
skin. 

Urban asserted that transplantation could not be made 
on surfaces having a tendency to perish when the cover- 
ing of soft parts is removed, for instance, bone, tendons, 
aponeuroses, and cartilage; and this is to a large extent 
true, although not strictly so, as has been abundantly 
proved. It must not be forgotten, however, that skin 
grafts can never be covered up within the tissues, for in- 
stance, as a substitute for a tendon sheath or a lost portion 
of peritoneum or dura mater, because of the impossibility 
of obtaining reliable asepsis. 

A few of the writer's cases, briefly reported, will serve 
to illustrate the applicability of the Thiersch method: 

The hand of a boy had been badly crushed. The entire dorsum 
was occupied by a granulating surface which presented little tendency 
to heal. If healing had occurred, there would have been much de- 
formity from contraction. The dressings were all removed on the 
ninth day after the transplantation, and the grafts found adherent. 
The superficial epithelium came off over a small area, but was soon 
reformed. The patient was seen as late as two years after the opera- 
tion, the new skin being in excellent condition, perfectly pliable and 
free from contraction. 

In another instance several crural ulcers were grafted that had 
existed eight or ten years, the patient spending considerable time in 
the hospital during that period. At the end of ten months the ulcers 
still remained healed, with no puckering of their surfaces. The 
patient was a heavy drinker and did the work of a hostler. 

An interesting case was one in which the right foot had been badly 
crushed in a railroad accident. The member was finally saved, but 
with the loss of a large amount of skin over the inner side of the 
foot and ankle and posterior portion of the sole including the heel — • 
an area somewhat larger- than the entire hand. A Wladimiroff- 
Mickulicz operation was discussed, but it was determined to try skin 
grafting first. The grafts adhered without difficulty, and the wound 
was soon well ; although a small ulcer in the vicinity which was not 
grafted failed to heal for several weeks thereafter. This might be 
considered an instance in which Thiersch grafting saved a foot from 
amputation. 



THE METHOD OF THIERSCH 59 

An extensive burn of both feet and the anterior surfaces of both 
legs in a little girl had caused such extreme contractures that the 
feet were drawn up almost against the tibiae. The physician in 
charge, after dissecting out the cicatricial masses and straightening 
the limbs, attempted to fill in the large remaining wound surfaces 
with pedunculated flaps from the adjacent uninjured regions of the 
legs. The flaps, however, sloughed, leaving the child's condition 
worse than before. The raw surfaces were then scraped and covered 
with Thiersch grafts, which all grew vigorously. The child was 
heard from six months or more after the operation; there had been 
no contraction, no ulcers had formed, and the result was satisfactory. 
A large epithelioma was removed from the frontal region, leaving 
the dura exposed over an area the size of a saucer. This was grafted 
at once, using the dry method. The result was perfect, notwith- 
standing that the wound was thoroughly septic. After several weeks 
the patient was again seen, and the grafts found in good condition. 
Every surgeon knows what a tedious process the healing of such a 
wound is under ordinary circumstances. 

In the case of a young lady, a fairly large nevus (port-wine stain) 
disfigured the lower eyelid and the upper portion of the cheek. This 
was excised down to the subcutaneous tissues, and the edges of the 
wound brought together as far as possible with sutures, leaving an 
opening as large as a silver half-dollar, which could not be closed 
without danger of drawing dowm the margin of the lid. The gap was 
filled with a single moderately thick graft and covered with a wet 
dressing. The transplantation succeeded, and in the course of time 
the skin became pliable. At the end of eight or nine months not 
the slightest puckering of the lid had resulted. Although the graft 
could still be easily detected, it continued to approach month by 
month more nearly to the appearance of the surrounding skin. 

Failure resulted in the case of a young and healthy man with a 
large ulcer of the leg occupying the site of a sear due to a crush. 
The ulcer had existed for years with no tendency toward healing. 
In operating, the tissues were found so dense and fibrous that a 
properly soft and bleeding surface could not be obtained, even by 
criss-crossing the floor of the ulcer with incisions. The grafts ap- 
parently dissolved under the wet dressing. It would undoubtedly 
have been better to have dissected out the entire cicatrix before graft- 
ing- 

In a case of epithelioma of the nose, the tissues were peeled from 
the bony framework, leaving only the periosteum. Grafts placed 
upon this surface "took" without difficulty, the process of healing 
being greatly shortened and the disfigurement lessened. 

In excising an epithelioma from the bridge of the nose, a circular 
piece of skin the size of a silver quarter was removed. In two or 
three weeks the graft, which was at first considerably sunken, became 



60 SKIN" GRAFTING 

elevated to the level of the surrounding surface. There was no con- 
traction and but a slight rounded cicatrix at the border of the trans- 
planted skin. 

In another case, quite an extensive area of tuberculous skin was 
removed from the inferior maxillary region of a small boy. A 
Thiersch graft filled in the defect quite satisfactorily, although some 
contraction took place about the edges. In such a case the surgeon 
operates with a freer hand and a better chance of eradicating the 
disease when he is conscious that the loss of tissue can readily be 
replaced. 



Thiersch Grafting in Special Cases. 

Accidental wounds are frequently permitted to gran- 
ulate before transplantation is done, as it is- often impos- 
sible to render them surgically clean and, in addition, the 
patient may be bleeding excessively or in a condition of 
shock. If everything is reasonably favorable, however, 
grafting should be done at once, as it may prevent subse- 
quent infection. 

Burn's. — As a matter of course, granulation is always a 
first requisite in burns. If the part can be kept aseptic, 
the new skin may be applied in about six weeks, and the 
time should even be longer if extensive sloughs must sepa- 
rate (Urban). Judicious grafting in large burns of the 
third degree cannot be too strongly urged, in order to pre- 
vent long-continued and exhausting suppuration, unsightly 
scars, and embarrassing contractures. 

Dunham 25 succeeded with a thick Thiersch graft in 
bridging over a finger-joint exposed by a burn, but this 
was a piece of good fortune which cannot frequently be imi- 
tated, the covering over of hollow spaces being a matter 
of plastic surgery rather than of transplantation. 

The Nose. — The results of Thiersch grafting about the 

25 Ref. Handbook Med. Sci., Supplement. 



THE METHOD OF THIERSCH 61 

nose are reasonably good, even when the entire covering 
of the organ has to be removed, providing the mncosa re- 
mains uninjured. When, however, so flimsy a framework 
as the mucous membrane alone exists, it is better to plug 
the nostrils with cotton so as to obtain a firmer basis. The 
grafted alee are at first quite thin, but in the course of 
time they become thick enough to be presentable. 

It is sometimes desirable to use pedunculated flaps of 
skin in repairing defects about the nose or lips involving 
the entire thickness of the part. When this is done, their 
raw surfaces may be covered with Thiersch grafts, either 
at once or after granulation has taken place, in order to 
prevent contraction. In replacing a portion of the cheek, 
for instance, a flap may be dissected from the neck, sup- 
ported on a piece of gauze for ten days or two weeks, and 
grafted before insertion in its new position. The wounds* 
from which these flaps are taken may also be grafted when 
necessary. . 

In the worst form of acne rosacea the cutaneous sur- 
face of the end of the nose becomes irregularly hyper- 
trophied, so that the grotesquely enlarged organ has a 
swollen, red, and nodular appearance. Such unsightly 
noses can sometimes be pared down to a proper size, and 
the surface at once grafted, the results being often cos- 
metically good. 

Xew Growths, — The Thiersch procedure has a wide 
field of usefulness in filling the defects left by the removal 
of malignant tumors, particularly carcinoma of the breast. 
With an effective method of grafting at his disposal, the 
operator does not fear to excise an amount of skin which he 
would otherwise hesitate to do, and it is in the skin that 



62 SKIN GRAFTING 

the majority of relapses occur. Kraske 26 found it pos- 
sible to graft the ulcerated surfaces of inoperable car- 
cinomata, thus preventing septic infection and offensive 
discharge ; but it is questionable if such a course is worth 
while, as the grafts soon break down and disappear. 

In excising hairy moles, it is necessary to be sure that 
the hair bulbs are completely removed; otherwise hairs 
force themselves through the new epidermal covering, as 
happened in a case reported by Gnarch. 27 

Hands and Fingers. — In injuries and burns of the 
hands, grafting is of immense service in the prevention of 
unsightly scars and annoying contractures. The Thiersch 
method may even be used with considerable success upon 
the palmar surface, although better and more durable re- 
sults are obtained, especially when the knuckles and wrist 
are involved, by means of pedunculated flaps from various 
portions of the body, or by the Wolfe-Krause method. 
Skin grafts may be employed with satisfaction in opera- 
tions for syndactylism. 

Scabs, and Contractures. — One of the most useful 
applications of Thiersch grafting is in the prevention and 
removal of deformities, due to extensive scars and con- 
tractures. Where possible, it is usually preferable, for 
the sake of nutrition as well as for cosmetic reasons, to 
dissect out the cicatricial tissue entirely. In contractures 
about the neck, for instance, where the chin is drawn down 
toward the sternum, the entire scar should be removed prior 
to the application of grafts. It should be noted, however, 
that pedunculated flaps or Wolfe-Krause grafts are often 

26 Munch Med. Woch., Jan. 1, 1889. 

27 Verhand. Internat. Med. Cong. Berlin, 1890, p. 224. 



THE METHOD OF THIERSCH 63 

more serviceable and sightly than are Thiersch transplan- 
tations. 

Grafting- on Bone. — Following sequestrotomy and 
other bone operations nmch time is often consumed in heal- 
ing. A few judiciously applied skin grafts will, however, 
frequently hasten convalescence, although they are less 
likely to "take" than under most other circumstances. 
Even the entire orbit may be lined with epithelium after 
the removal of a malignant growth, as was successfully 
done by von Noorden. 28 

In some cases, where a smooth, clean surface can be ob- 
tained, transplantation may be done at once, although it 
is often preferable to wait until granulations have ap- 
peared, perhaps four to six weeks. When a gutter has 
been chiseled in the bone, it may be necessary to shove 
the grafts through quite a small opening, and much dif- 
ficulty may be experienced in adjusting them smoothly. 
They may sometimes be held in place by packing the cavity 
with small pledgets of gauze. Even when success is but 
partial, the remainder of the surface is often stimulated 
to rapid healing. After the removal of exostoses, the bone 
may at once be covered with new skin with considerable 
assurance of a good result. 

Chronic Empyema. — In this troublesome affection it is 
sometimes necessary to remove portions of the chest wall 
in such a manner as to leave a large granulating cavity 
which is very slow in healing. Tillmanns, in 1890, dem- 
onstrated that such surfaces can be successfully grafted, 
and since then, the operation has been repeatedly done by 
others. 

2S Berl. Klin. Woch., 1892, No. 41. 



64 SKIN" GRAFTING 

Bedsores, after the breaking-down process has ceased, 
can sometimes be provided with an epithelial covering, 
either with or without preliminary cnrettement, thus sav- 
ing time, disfigurement, and annoyance. 

Chronic leg ulcers present such a severe test of any 
form of grafting that methods will often fail which uni- 
formly succeed elsewhere. Urban, however, is so confident 
that Thiersch grafting, when properly carried out, will be 
effective in these cases, that he says amputation should 
never be resorted to even in the most extensive lesions ; but 
his elaborate method requires so much time, care, and pa- 
tience that it can scarcely be considered advisable except 
in aggravated cases. Three to four months are necessary, 
six to eight weeks of which must be spent in preparation 
alone, and during the entire time the patient must remain 
in bed ! 

It is advisable in many instances to completely excise 
ulcers of the leg, almost as if they were malignant growths, 
before transplantation is attempted, especially if much in- 
duration is present; and failures would undoubtedly be 
much less frequent if this were more often resorted to. 
Excision is of course inevitable if lupus or epithelioma 
exists. 

The cause of the ulcer must be carefully considered, for 
upon this may depend the character of the operative pro- 
cedure. In various ulcers, for instance, the enlarged, veins 
should always receive attention, either by obliterating them, 
by means of one of the various procedures employed for 
that purpose, or by applying a suitable support to the leg, 
in the shape of a bandage, an elastic stocking, or a Murphy 



THE METHOD OF THIERSCH 65 

corset. Prolonged rest in bed will of conrse improve the 
nutrition of the limb, but the old condition returns as soon 
as the patient resumes his feet. Syphilis is always a con- 
traindication to operation until appropriate treatment has 
been used for a sufficient length of time to insure local free- 
dom from the disease. 

Following a transplantation for leg ulcer, the patient 
should remain in bed for some time, as a sudden afflux of 
blood to the part often injures the tender grafts, and an 
elastic flannel bandage should be worn for several months, 
reaching from the toes to the thigh. Some mild ointment 
should occasionally be applied to the grafted area in order 
to prevent excessive dryness, and great care must be exer- 
cised in the avoidance of injury to the limb. 

Urban lays much stress upon massage in the after-treat- 
ment. This should be begun in the vicinity of the ulcer 
upon the tenth day, and the longer it is continued the bet- 
ter. The new skin may be rendered pliable without actu- 
ally touching it by carefully pulling and massaging the 
skin in its vicinity. 

• Mucous Surfaces. — Thiersch grafting has been success- 
fully done in the mouth, the vagina, the urethra, the eye, 
and the ear, although the chances of success are not so good 
in these situations as elsewhere. The statement made by 
Thiersch is not strictly true, that it is impossible to graft 
upon surfaces connected with mucous cavities, Schnitzler 
and Ewald having succeeded even upon a granulating sur- 
face, following the removal of an epithelioma from the in- 
side of the cheek. The new skin soon conforms more or 
less to the characteristics of the surrounding mucous mem- 



66 SKIN GRAFTING 

brane, although not becoming identical with it. Hairs or 
glandular elements never develop, partly because of the 
thinness of the grafts. 

It is occasionally possible to form a new urethra, in oper- 
ations for hypospadias, or to replace lost portions of the 
urethral canal by means of Thiersch grafting, the grafts 
being wound around a catheter, which is left in situ until 
adherence has taken place. 

Heterogeneous Thiersch Grafting. 

As in other forms of transplantation, skin taken from 
the patient himself grows better than that obtained from 
others, even from a blood-relation. When, however, it is 
necessary to employ the heteroplastic method, local anes- 
thesia (see Chap. X) should always be used, if possible, in 
order to avoid danger to the donor. In extensive burns 
occurring in children, for instance, it may be advisable to 
obtain grafts from another, usually the mother or the 
father. When this is the case, the two individuals may be 
placed side by side, the grafts removed under local anes- 
thesia from the parent being transferred directly to the 
unscraped granulating surface on the child without causing 
pain to either of them. 

Statistics. 

In order to give some idea of the proportion of successes 
obtained in Thiersch grafting, the following statistics are 
quoted : 

Eancrede 29 estimates that seven out of ten operations 
succeed ; but if the cases are at all well selected, the pro- 

29 Ann. Gyn., Feb., 1892. 



THE METHOD OF THIERSCH 67 

portion should be greater than this. Thorndike has col- 
lected 123 cases with 102 successes (82.9 per cent). 
Jungengel's statistics show 119 transplantations with 100 
successes. Yon Eiselsberg 30 reports 37 operations on 
fresh wounds with 33 good results, and 13 operations on 
granulating wounds with 11 good results. Plessing 31 tab- 
ulates 78 graftings with 58 successes (75 per cent) and 12 
partial successes. Out of 544 cases of grafting by various 
methods, collected by Davis from the reports of the Johns 
Hopkins Hospital, 341 were completely successful, and but 
17 were absolute failures. 

30 Wien. Klin. Woch., 1889, Nos. 34 and 35. 
3 1 Arch. f. Klin. Chir., Bd. 37, p. 53. 



CHAPTER V 
THE WOLFE-KRAUSE METHOD 

The credit for introducing the use of grafts filling the 
entire cutaneous defect and comprising the whole thick- 
ness of the skin, without including fat or cellular tissue, 
is due to J. R. Wolfe, an oculist of Glasgow. His first 
experiments were made in connection with the conjunctiva, 
portions of which he shifted, without pedicels, from one 
part of the eye to another. He soon began to employ the 
conjunctiva? of rabbits in repairing defects in the human 
eye, announcing his method before the Glasgow Med. and 
Chir.' Soc, in 1872. In 1875, he published his experi- 
ments in skin grafting for ectropion, 1 being closely followed 
by Wadsworth, who introduced the procedure in America. 
Von Esmarch was among the first to apply the operation to 
any extent in general surgery. 2 

Grafts composed of the entire thickness of the skin had 
been used frequently enough, however, prior to their em- 
ployment by "Wolfe, not only by the ancient Hindus, but 
in modern times as well, although the subcutaneous tissues 
were nearly always included. Jacenko 3 was probably the 
first to successfully employ grafts devoid of fat, and in 
1872, Le Eort reported a successful operation in a case of 
ectropion. 

Wolfe was probably correct in believing that the avoid- 

iBrit. Med. Jour., Sept. 18, 1875. 

2 Wien. Med. Woch., 1885, Nos. 29 and 30. 

3 Ber. Klin. Woch., Xo. 8, 1871. 

68 



THE WOEFEKKRAUSE METHOD . 69 

ance of fatty tissue was an important feature of his method, 
as it is apt to undergo necrosis and to interfere with nutri- 
tion. This has been denied, however, by many, including 
Hirschberg 4 and Taylor, 5 and there is no doubt that suc- 
cess can often be obtained without this precaution ; in fact, 
free masses of fat alone are not infrequently transplanted 
from one locality to another, in order to fill up unsightly 
depressions, a substitution for the mammary gland having 
even been provided in this manner. Wolfe's original 
method has been modified, and the technic so much im- 
proved by Fedor Krause, that it is often referred to as the 
Wolfe-Krause Method. 

Preparation. 

If an ulcer is to be operated on, its preparation must 
be undertaken with even greater care than in the Thiersch 
process (see Chap. IV). After curetting away the granu- 
lations, there should be no hesitation in excising the cal- 
lous borders and base, so as to obtain as free a circulation 
as possible ; and in some cases — for instance, in old crural 
ulcers — it may even be advisable to chisel away a layer of 
thickened and diseased bone from the face of the tibia. 
Rather than employ ligatures on the wound surface, it may 
occasionally be preferable to delay operating for a day or 
so and apply compression, afterward soaking off the com- 
press so as not to renew the bleeding; or direct pressure 
with an Esmarch bandage may be used (see p. 37). 

Contrary to former belief, it has been demonstrated 
(Davis 6 ) that good results can be obtained by placing 

*Verhand. d. Deut. Gesell. f. Chir., 1893. 

3 Practitioner, Dec, 1882, p. 428. 

6 Internat. Clinics, 1905, Vol. 1, p. 81. 



70 SKIN GRAFTING 

whole thickness grafts directly on a healthy granulating 
surface, without preliminary curettement. The granula- 
tions should be cleaned the day before the operation, how- 
ever, and a mild antiseptic dressing applied. Such grafts 
are at first higher than the surrounding skin, but they soon 
come down to the common level. Although it is question- 
able if success is as certain as when the granulations are 
removed, it is nevertheless well to know that under certain 
circumstances the operation may be simplified in this 
manner. 

Technic. 

The grafts are best cut in the shape of a spindle, so that 
the defect produced by their removal can be closed by 
sutures, although in fleshy individuals it may be necessary 
to dissect the fat from the bottom of the wound before it 
can easily be united. 

The arm or the thigh is usually chosen, but owing to the 
fact that the skin retains almost indefinitely its original 
character of fineness or coarseness, it is well to use on 
the face grafts from the inside of the arm. Aside from 
this consideration, it is of little moment, contrary to 
Hirschberg, where the grafts are obtained, or whether the 
blood plexus is highly developed or not, and it is unneces- 
sary to produce an artificial hyperemia by preliminary 
irritation of the cuticle. Davis suggests using skin from 
the abdomen obtained in the course of a laparotomy. 
Hueter and Krause claim that hairs may be transplanted 
by this method, although they are apt to be deformed and 
rather few in number. An eyebrow, for instance, might 
thus be replaced from the pubes. 



THE. WOEFErKRAUSEl METHOD 71 

The graft should be carefully outlined by an incision. 
Then one end is seized with forceps, and the whole flap is 
freed with the knife, the edge of which is turned toward 
the surface so as to remove the fat, although the retention 
of a small amount will do no serious harm. At least one 
third should be allowed for shrinkage, which is always 
great, owing to the elasticity of the skin. In order to 
avoid touching the raw tissues more than is necessary, 
which is detrimental to their vitality, it is best to fold the 
end of the spindle under as soon as enough is loosened, so 
as to bring the two raw surfaces together and permit han- 
dling of the graft by its epithelial covering only. Rough 
handling should be avoided with the greatest care, such as 
tight pinching with forceps, rubbing with gauze, or un- 
necessary traction before the graft is completely divided. 

Young 7 excises the subcutaneous fat along with the 
grafts, afterward trimming it off with curved scissors while 
the flap is spread on the palm of the hand or is curled over 
a finger. He claims that less time and trouble are thus 
required and that the resulting wound is more readily 
closed. Adipose tissue soon reforms beneath the trans- 
plantation, in sufficient amount to fill up inequalities and 
render the skin pliable. 

An essential feature, according to Krause, is absolute 
dryness, surgically speaking, which he thinks is conducive 
to rapid healing. There must be no douching and no mois- 
ture about the hands or instruments or about the surface 
upon which the grafting is to be done. He is probably 
correct in this, although there are others who do not agree 
with him. 

7 Glasgow Med. Jour., Oct., 1907. 



72 SKIN GRAFTING 

Adjustment of Grafts and Dressings. 

The grafts, cut into smaller pieces if desirable, are 
pressed firmly in place in order to remove blood and bub- 
bles of air, and if too much moisture is not present, they 
will adhere as if giued fast. Subsequent bleeding beneath 
the surface is fatal. Sutures are detrimental and are 
never necessary, except occasionally about the eyelids and 
lips, although they were at first invariably employed by 
Wolfe. 

The entire wound must be completely covered with as 
large sections of skin as possible, because wherever there 
is an open space more or less of a cicatrix results. If this 
is not practicable, the operation may be completed with 
Thiersch grafts. 

It was at first customary to keep the new skin warm by 
applying artificial heat ; but this was found' to be detri- 
mental rather than beneficial, as decomposition was thus 
favored. Either a dry or a moist dressing, as described 
under the Thiersch method, may be used, but the former 
is usually preferable, nothing but ordinary sterilized 
gauze and cotton really being necessary. The grafts 
should be inspected in three or four days in order to open 
blisters, etc., the gauze being soaked off with warm boric 
acid solution if strips of rubber protective have not been 
employed. After this, sterilized borated vaselin can be 
used. 

After-treatment. 

Inequalities of the surface soon fill out as they do under 
Thiersch grafts. If the outside layers of the new skin 
exfoliate much, a moist covering can be used to hasten the 



'•''■■. 



THE WOLFEhKRAUSK METHOD 73 

process, and the lost epithelium replaced by Thiersch 
grafts, if necessary. Even when the surface rises in 
blisters and assumes a bluish color, failure should not has- 
tily be assumed, as the necrosis is often superficial and of 
comparatively slight importance. 

Healing should be complete in from three to six weeks, 
success being aided by massage and other measures as in 
the Thiersch process. Without actually massaging the 
grafts themselves, they may be loosened quite early by 
manipulating the skin in their vicinity. 

With proper care whole thickness grafts may be em- 
ployed wherever the Thiersch method is applicable, even 
upon tendons, bones, and aponeuroses ; but its greatest use- 
fulness begins where that of the Thiersch graft ends — that 
is, where an especially thick and durable covering is re- 
quired — although the technic is much more exacting and 
the chance of failure greater. Davis, 8 however, has re- 
ported 19 cases of grafting with the whole thickness of the 
skin with but one partial failure, which is certainly en- 
couraging. 

8 Ann. Surg., 1909, Vol. 50, p. 542. 



CHAPTEK VI 

THE METHOD OF HIRSCHBERG— SKIN-PERI- 
OSTEUM-BOKE GRAFTS 

In the original "Indian method/' as used by the ancient 
Hindus in rhinoplastic operations, grafts were employed 
comprising the subcutaneous fat ; and nearly all the trans- 
plantations which were done up to the time of Wolfe, with 
the exception of that introduced by Reverdin, were pat- 
terned after this method, as is most' plastic work at the 
present time. 

Hirschberg x has attempted to revive the Indian method, 
but has met with little response from other surgeons. He 
claims that better results will be obtained by transplanting 
the subcutaneous adipose tissue along with the cutis, and 
supports his assertion by calling attention to cases in which 
pieces of fat alone have been used to fill up various defects 
in the tissues, even to the replacement of the entire mam- 
mary gland (Czerny). It is interesting to note, however, 
in this connection, that Pitschke has called attention to the 
necrosis of adipose tissue which often follows surgical oper- 
ations, causing troublesome fistulse, thus showing that the 
vitality of fat is not great. 

Hirschberg 2 lays great stress on the amount of blood 
and other fluids which the graft contains at the time it is 
transplanted, with the idea that it subsists until new vessels 

1 Verhand. d. deut. Gesell. f. Chir., XII Kong., 1893. 

2 Verhand. d. deut, Gesel. f. Chir., XXIV Kong., 1895. 

74 



■HH 



THE METHOD OF HIRSCHBEEG- 75 

are formed almost entirely upon the nutritive material al- 
ready within its substance ; and in this connection DiefTen- 
bach, Thiersch, and Hanfr have shown that for some time 
after the removal of a thick portion of cuticle there is more 
or less perceptible motion of its fluids. 

Hirschberg also believes that not a little depends upon 
the locality from which the skin is derived, some portions 
of the body being richer in vessels than others, which ac- 
counts, he thinks, for the comparatively ready reunion of 
severed portions of noses and fingers. The success of the 
Hindus, he attributes partially to the fact that they usually 
grafted from the gluteal region, where the skin is very 
vascular. 

Hence, he advises artificial irritation of the skin by 
means of rubbing it, or beating it with a piece of rubber 
tubing, until the surface becomes red and swollen ; and in 
order to further increase the congestion of a limb, an Es- 
march strap may be lightly fastened about it. The gen- 
eral opinion is, however, that but little if any benefit is 
derived from the production of artificial hyperemia in skin 
grafting. 

Sutures are often desirable in the method of Hirschberg, 
as the grafts will not adhere readily without them. As a 
matter of convenience, he often places them in position be- 
fore entirely detaching the flap. 

Morrow 3 has utilized the Hirschberg method by remov- 
ing -small defects from the face and other regions with an 
instrument known as "Keyes' cutaneous punch," and filling 
the hole thus left with a button comprising the entire thick- 
ness of the skin together with the subcutaneous fat, which 

3 Trans. Am. Derm. Assoc, 1891. 



76 SKIN GKAFTTNG- 

is removed in the same manner from some other region. 
He claims that hair may easily be transplanted in this way. 

Skin-Periosteum-Bone Grafts. 

It should be mentioned that grafts are occasionally em- 
ployed which include not only the skin and subcutaneous 
tissues, but also the periosteum and even a portion of the 
bone itself. The technic, however, is very exacting, and 
asepsis must of course be absolute. The indications for 
this method of transplantation are not numerous and are 
confined mostly to certain rhinoplastic operations and to the 
filling in of defects in connection with the skull and scalp. 

In outlining the graft, which is usually obtained from 
the anterior surface of the tibia, the incision is made di- 
rectly down to the bone, a more or less thin layer of which 
is then removed with a sharp chisel without disturbing its 
connection with the super j acent periosteum and skin. The 
tibial wound is then closed by undermining and suturing 
the surrounding integument. Better results are usually 
obtained when a section of bone is included than when the 
periosteum alone is employed. 



CHAPTER VII 

THE TRANSPLANTATION OF MUCOUS . MEM- 
BRANE— ANOMALIES IN SKIN GRAFTING— 
SPONGE GRAFTING 

Mucous Membrane. 

The first systematic transplantation of mucous mem- 
brane, other than the conjunctiva, was done by Wolfler, 
who grafted urethras, after the excision of strictures, with 
strips of mucosa from a prolapsed rectum, from the cervix 
of a prolapsed uterus, or a uterus which had been removed 
from the body. Subsequently he similarly obtained good 
results with the stomach of the frog, the esophagus of the 
rabbit, etc. In one of his cases the condition of the new 
urethra was perfect at an autopsy made six months after 
the operation. Beigel x also did some excellent work in 
this line, and Fenwick 2 repaired a defect in a human 
urethra with a portion of the urethra of a sheep. 

It should be mentioned in this connection that the 
urethra has recently been satisfactorily replaced with por- 
tions of the internal saphenous vein as well as with the 
ureter and the vermiform appendix, removed from other 
individuals during the course of necessary operations. 

Wolfler claims that mucous membrane adheres as well 
as skin, but this has not been the experience of others. 1 1 

1 "Die Krankheiten des Weibl. Geschlechtes, " 1875. 

2 Lancet, Feb. 8, 1896, p. 3.53. 

77 



78 SKIN" GRAFTING 

can be shaved off as in Thiersch grafting, or may be 
stripped off in its entirety. 

Hirschberg, in 1874, made the first transplantation of 
buccal mucous membrane to the conjunctiva. Since that 
time the experiment has been frequently repeated. To 
Wolfe, in 1872, is due the credit of grafting from the con- 
junctivae of animals to that of man, and of bringing the 
procedure into general use. 

Czerny showed that mucous membrane from the mouth, 
with flat epithelium, and from the nose, with cylindrical or 
ciliated epithelium, soon comes to resemble epidermis when 
grafted upon a raw skin surface. Sick 3 has observed that 
the same phenomenon occurs in connection with vaginal 
mucosa. 

Most writers, following the teaching of Virchow, main- 
tain that skin transplanted to a mucous surface becomes 
transformed into mucous membrane. It is certainly true 
that in most cases it very largely conforms itself to its 
surroundings, losing its hairs and other distinctive fea- 
tures. Thiersch, 4 however, denies that this change takes 
place, citing as proof a case in which he used a skin-flap in 
manufacturing a soft palate. So much hair grew upon the 
part that the patient was compelled to continually shave 
the inside of his mouth ! 

In operations for hypospadias Thiersch grafts have been 
successfully employed to line the new urethra, by wrapping 
them around a catheter, which is left in position until ad- 
hesion has taken place. 5 They have also been used within 
the larynx after the excision of a stricture. 6 • 

3 Archiv. f. Klin. Chir., Bd. 43, p. 387. 

±Beitrage z. Cent. F. Chir., 1888, No. 24. 

5 Nove-Josserand, Rev. de Chir., 1903, Vol. 1, p. 403. 

6 Alapy, Zentralbl, f. Chir., 1900, p. 1313. 



ANOMALIES IN SKIN GRAFTING 79 

Anomalies in Skin Grafting. 

Kibler, 7 Parmenter, 8 and Granbury 9 insist that shavings 
from callosities of the palms of the hands or soles of the 
feet furnish particularly good material for grafting, having 
the advantage of being easily obtained without pain or 
other inconvenience to the patient. From three to six or 
more grafts, as thin as tissue-paper, may be cut from 
the same surface at intervals of three or four days. In the 
experience of Kibler and others over 80 per cent of the 
transplanted pieces of epithelium have lived, the results 
being excellent. 

Granbury recommends preliminary friction of the callus, 
imagining that the vitality of the grafts is increased and 
union hastened. Experience has proved, however, that in 
other situations irritation of the skin prior to transplanta- 
tion is of little or no value, and it is difficult to see why it 
should be otherwise where callus is concerned. 

Hodgen 10 was successful in grafting with shavings from 
corns, preferring this material to that otherwise obtained. 
Leale n had good results with warts, his method being to 
separate the growth into its component vascular "epithelial 
rods," which were scattered over the ulcerated surface. 
He attributed his success to the superabundant tendency to 
growth, which verrucosities are supposed to possess. Hod- 
gen has also transplanted from mollis, but it is difficult to 
imagine why this should ever be done, particularly as there 
is some danger of transferring malignancy in this way. 
. The fact that pieces of old, dried, and often loose 

7 Jour. Am. Med. Assoc, Aug. 8, 1891, p. 224. 

8 Park's Surgery, 1896. 

9 Texas Sanitarian, Sept. 1894. 

10 St. Louis Med. and Surg. Jour., July, 1871. 
"Med. Rec, Vol. 14, p. 188, 1878. 



80 SKIN GRAFTING 

epidermis could be used in grafting was also demonstrated 
by Hodgen, his experiments being confirmed by Lnsk. 12 
When desirable, almost unlimited quantities of epithelium 
can be obtained by the application of a canthakides blis- 
ter, as was first suggested by the writer, 13 and afterward 
by Morris 14 and by Lusk. It is unnecessary to dry the 
epidermis, as is recommended by Lusk, but it can be used 
at once, as it is cut from the blister, small pieces furnishing 
better results than large ones (Morris). It is true that 
"blister grafts" are not as durable as those obtained by 
other methods, and that they are best adapted for use on 
certain small wounds and granulating surfaces, although 
Lusk, by using very small pieces, claims to have obtained 
good, durable, elastic skin. 

Schweninger observed that when hairs were placed upon 
an ulcer a growth of epithelium resulted; but von Nuss- 
baum showed that this occurred only when the root sheaths 
were present, and that the hairs themselves were of no im- 
portance. The process, then, amounts simply to a trans- 
plantation of epithelium, and is of little practical value. 

Howard 15 claims to have grafted ulcers with bits of 
muscle, which grew well and stimulated the remainder of 
the surface to rapid cicatrization. This does not mean, 
of course, that epithelium can develop from muscle as has 
been asserted. 

It has long been known that scrapings from the surface 
of the skin, so-called "epithelial dust," will adhere to 
granulations or to fresh wounds and grow as do larger 
grafts. Reverdin tried the experiment and reported 

12 Med. Rec, Dec. 7, 1895, p. 800. 

13 Denver Med. Times, May, 1895, p. 428. 

14 Lectures on Appendicitis and Notes on other Subjects, N. Y., 1895. 

15 N. Y. Med. Jour., Sept., 1871. 



ANOMALIES IN SKIN GRAFTING 81 

against it, as did also Czerny, Reclus, and others, although 
Fidder and Hodgen claimed to have had good results, espe- 
cially the latter, who employed scrapings from the sole of 
the foot. It would seem probable that the less the sup- 
puration the greater the chance of success, as the tiny grafts 
would not be so likely to become macerated or washed away. 

In this connection the method of Mangoldt 16 possesses 
some merit. He carefully disinfects the skin and scrapes 
it with a scalpel until a sort of paste is procured, formed 
of epithelial scales and a little blood. This is smeared 
upon the surface of the ulcer, to which it readily adheres, 
owing to the coagulation of the blood, forming a brick-red 
layer. In five to seven days the blood vanishes, leaving 
new pinkish skin, which becomes firm in about three weeks. 
A fine mosaic is seen with a lens, but to the naked eye it 
is smooth epidermis. Mann, of Dresden, has utilized the 
method in open wounds following operations upon the 
mastoid. 

Grafting from dead bodies or from amputated 
limbs is easily done and has frequently been resorted to ; 
but the danger of carrying disease is positive and cannot be 
disregarded, while failures are much more frequent than 
in autodermic methods. Czemy reports cases of tubercu- 
losis, communicated by grafts obtained from a leg removed 
for white swelling of the knee, and there is always danger 
from syphilis. 

Girdner 1T claims that the method is original with him, 
but the credit probably belongs to Steele, of Bristol, who 
made successful transplantations from amputated limbs in 

16 Deut. Med. Woch., Nov. 28, 1895, p. 798. 
17 Med. Rec, July 30, 1881. 



82 SKIN" GEAFTING 

several cases. Ivanova 18 has transplanted with much suc- 
cess from the bodies of infants, one and one-half and two 
hours after death. In grafting from amputated limbs, 
Symonds 19 sometimes employed the Thiersch method and 
at other times that of Wolfe. Tillmanns, in his work on 
surgery, advances the questionable idea that in transplant- 
ing from the cadaver the operation must be performed be- 
fore rigor mortis sets in. 

Each of the above-mentioned means of obtaining grafts 
is of scientific interest, and may be of practical use in 
certain cases ; but none of them is of so much general value 
as the method usually employed. Grafting with hairs, 
moles, or Avarts would scarcely be considered under ordi- 
nary circumstances. 

Sponge Grafting. 

Sponge grafting, introduced by Hamilton, in 1881, is 
essentially different in principle from skin grafting, never- 
theless a brief consideration of the subject will not be out 
of place. It was formerly in quite general use. Sponge 
does not grow fast to the surface as does skin, but acts 
merely as a stimulating support for the granulations, fin- 
ally undergoing complete absorption. The procedure is 
much inferior in its results to the transplantation of cuticle, 
and is now seldom employed. 

A fine Turkey sponge is selected, soaked in dilute 
nitrohydrochloric acid until all calcareous particles have 
been dissolved, and then placed for a time if desired in a 

18 Ann. Surg., Vol. 12, 1890, p. 354. 

19 Brit. Med. Jour., Dec. 14, 1889, p. 1331. 



SPONGE GRAFTING 88 

solution of potassium hydroxid. Very thin slices, which 
are the most serviceable, can be cut with a sharp knife, or, 
more conveniently, with a microtome, and sterilized by boil- 
ing, or in a 5 per cent solution of carbolic acid, which is 
afterward removed by washing. 

The sponge is then spread upon the granulations, which 
have been rendered as nearly aseptic as possible (see the 
method of Reverdin), and dressed much as if it were a 
transplantation of skin. The granulations soon acquire 
new energy and push their way into the interstices of the 
sponge, which often almost disappears beneath them, so 
luxuriant is the growth. Cicatrization proceeds more rap- 
idly than under ordinary circumstances, providing that 
sepsis and decomposition do not become too prominent, 
which is not infrequently the case. 

Robinson combines sponge grafting with the transplanta- 
tion of skin, small bits of which he places beneath the layer 
of sponge. He claims that the filling up of ulcers and the 
formation of epithelium go on side by side with unusual 
rapidity. 

The transplantation of fascia, 20 muscle, nerves, brain- 
tissue, blood-vessels, omentum, bones, joints, and even of 
entire organs, has recently assumed much prominence in 
surgical literature, but the consideration of these inter- 
esting subjects is scarcely in place in connection with a 
monograph on skin grafting. 

20 Davis, Ann. Surg., Dec. 1911. — Zeit. f. Chir., 1911, pp. 23 to 36. 



CHAPTER VIII 
GRAFTING FROM ANIMALS 

The idea of obtaining grafts from animals, thus avoid- 
ing pain and inconvenience to the patient, is certainly 
attractive. If it could be demonstrated that such trans- 
plantations were sufficiently often successful, and that the 
new skin was as satisfactory as that obtained by other 
processes, zoografting would be the method of choice. Un- 
fortunately the procedure is at best uncertain, so much so 
that Reclus has classed it among "laboratory experiments," 
rather than among useful operations. Colrat laid down 
the general rule that such grafts usually become absorbed, 
granulations sooner or later growing through them, al- 
though they may seem to thrive at first. This is un- 
doubtedly going too far, as numerous instances have been 
recorded where the method has been of great service. 

Cousin makes some interesting comparisons between the 
value of grafts obtained from man and from animals. He 
made 165 transplantations from frogs, chickens, guinea- 
pigs, and rabbits, out of which he had but 15 successes. 
In 122 human grafts, however, good results were ob- 
tained in 115. 

Success has varied much in the hands of different opera- 
tors ; so much so that by some the method has been abso- 
lutely condemned, and by others praised beyond all reason. 
A partial explanation of this lies in the fact that many 

84 



GRAFTING FROM ANIMALS 85 

results have been reported too soon, before time and ex- 
posure had tested the resisting powers of the new skin. 

Zoografting possesses an advantage over transplantation 
from another person in avoiding the danger of transmitting 
disease ; and where it would otherwise be necessary to call 
upon the patient's friends for epidermal donations, it is 
perhaps most in place. Even in these cases it is question- 
able whether it would not often be better to run the small 
amount of risk and obtain human skin from the bodies of 
recently dead infants, amputated limbs, circumcisions, etc., 
or from living individuals. 

One of the first recorded instances of grafting from an 
animal, to man, and certainly one of the most remarkable 
in medical literature, is said to have occurred in the seven- 
teenth century. A surgeon replaced a defect in the scalp 
and skull with a skin-periosteum-bone graft from a dog; 
but under threat- of excommunication, the Church com- 
pelled the unfortunate operator to remove the transplanted 
tissues, which had already grown in place. 

Zoografts have been obtained by various operators from 
frogs, chickens, lizards, pigs, dogs, cats, rabbits, guinea- 
pigs, the lining membranes of eggs, etc. Frogs furnish, 
perhaps, the most reliable and most easily obtainable mate- 
rial, although Miles 1 considers it to be the least desirable of 
all. 

Grafting- from frogs was performed by Allen, in 
1884, 2 and by Baratoux and Dubousquet-Laborderie 3 a 
few years later. The skin of the abdomen is usually em- 
ployed, but that from the back or any other portion of the 

1 Edinburgh Med. J., Sept., 1895. 

2 Lancet, Nov. 15, 1884. 

3 Le Prog. Med., Nov. 15, 1887. 



86 SKIN GRAFTING 

body answers the purpose equally well. Smith 4 affirms 
that the dorsal skin is thicker and grows more satisfactorily 
than that from other parts. Small pieces can be removed, 
or long strips, which may afterward be divided if desir- 
able. ]STesterovsky 5 pinches up a fold of skin with forceps 
and snips off a piece the size of a finger-nail, which is a 
rapid and satisfactory method. Fowler 6 skins the entire 
frog, legs and all, in strips % to % i ncn wide. 

In order to render everything as aseptic as possible, 
the frog, after a preliminary scrubbing, may be immersed 
as far as the neck for five minutes in a solution of corrosive 
sublimate (Nesterovsky), or allowed to swim about indefi- 
nitely in a solution of boric acid (Polaillon). 

The cuticle of frogs, as well as that of other animals 
and of man, may be preserved apart from the body for a 
number of hours; hence grafts wrapped in some water- 
proof tissue with moist gauze, to prevent drying, may 
safely be carried to patients at a distance (Allen). 

The new skin soon becomes pinkish and so nearly trans- 
lucent that one must observe rather closely at times to de- 
tect its presence; in fact, it occasionally seems almost to 
disappear, and then to reappear as a delicate film through 
which the red surface beneath can easily be seen. Should 
the grafts even vanish entirely, cicatrization is said to be 
promoted. The pigmentation, so universally present with 
frogs, disappears in a few days, — five, according to Smith ; 
ten, according to Fowler, — but, nevertheless, for some rea- 
son the new skin remains somewhat darker than the sur- 
rounding cuticle. 

4 Boston Med. and Surg. Jour., Jan. 24, 1895. 

5 Brit. Med. Jour., June 1, 1889, p. 1246. 
"Ann. Surg., Vol. 9, 1889, p. 179. 



GRAFTING FROM ANIMALS 87 

A soft, pliable covering is produced, which, were it only 
durable, would be all that could be desired ; but unfortu- 
nately it has a tendency to ulcerate and disappear, which 
renders frog's skin inferior to that obtained from the 
human body. Even under the most favorable circum- 
stances, great care must be given the soft and immature 
cuticle for at least three months. 

Redard 7 was the first to use the skin of chickens for 
grafting, and for a time this material became quite pop- 
ular, although, like other forms of zoografting, it is now 
seldom resorted to. The soft, nude cuticle on the under 
surfaces of the wings was selected, and the fat carefully 
removed. When the grafts survived, they ultimately came 
to resemble to a great extent the normal surface of the 
body. 

Altamirano 8 successfully grafted an ulcer with 20 pieces 
of cock's wattle:. The circulation in these structures is 
so vigorous that one would expect comparatively good re- 
sults. 

Miles, of Edinburgh, 9 and a few months later, M. E. 
Van Meter, of Colorado, 10 employed with considerable 
success the skin of puppies, Miles using the greyhound, 
and Van Meter the Mexican hairless puppy, which pos- 
sesses a particularly soft and white integument. The 
cuticle of a young pig has been utilized with satisfaction 
by Raven n and Hubscher. 

Miles 12 has also transplanted from rabbits and kit- 
tens. His method is to shave the abdomen, and if neces- 

7 Arch. Roum. de Med. et de Chir., Jan., 1888. 
s Satellite of the Ann. Univ. Med. Sci., Oct., 1889. 
9 Lancet, Mar. 15, 1890, p. 594. 

10 Annals Surg., Aug., 1890, p. 136. 

11 Brit. Med. Jour., Nov. 3, 1877, p. 623. 

12 Edinburgh Med. Jour., Sept., 1895. 



88 SKIN GRAFTING 

sary the flanks, and remove the cuticle in strips from one to 
six inches in length and from one-half to one inch in width, 
avoiding the subcutaneous cellular tissues. It is perhaps 
unnecessary to curette the granulating surface, but it should 
be healthy. The grafts are pressed down firmly, with 
their edges together, and the dressing should not be dis- 
turbed for from forty-eight to seventy-two hours, and then 
with the greatest caution. Superficial sloughs and pustules 
may form. The latter should be opened at once. Gran- 
ulations which show a tendency to grow through the new 
skin and destroy it should be removed with a sharp spoon. 
The color of the grafted skin soon becomes satisfactory, and 
sensation develops ; hair does not grow, and there is no con- 
traction. Miles reports four successes in 10 cases and only 
two absolute failures. 

As a matter of interest only, it should be mentioned that 
skin has been successfully grafted from man to the lower 
animals. 

E. Aievoli 13 made use of thin sections of the testes of 
rabbits for purposes of grafting in four cases, assuming 
that the testicle possesses a greater cellular activity than 
other portions of the body. The results were undoubtedly 
good, but it does not follow that they were better than could 
otherwise have been obtained. 

The lining membrane of an egg furnishes a material 
for grafting which is easy to obtain and is sometimes effica- 
cious, although the results are not so durable as they might 
be, in spite of the views of Watson and others to the con- 
trary. Amat 14 achieved some success in this way in cases 

"Cent. f. Chir, No. 14, 1891, p. 289— Med. Rec, Aug 6, 1892, p. 164. 
"Arch. d. Med. et de Pharm. Milit., Mar., 1895 — Medicine, Oct., 1895. 



GRAFTING FROM ANIMALS 89 

of extensive burns. Small pieces were placed 12 to 15 
millimeters apart and covered with sections of tin foil 1 
cubic centimeter square. An ingenious application of the 
method has been used by Berthold, in closing perforations 
of the tympanum (see grafting in connection with the ear). 
The procedure has been of value in filling defects in the 
conjunctiva, such, for example, as are produced by the re- 
moval of a pterygium. 



CHAPTER IX 

GRAFTING IN LUPUS, IN X-RAY BURNS, ON 
THE CRANIUM, AND IN CONNECTION WITH 
THE EYE AND EAR 

Lupus. 

This is a stubborn tuberculous affection of the skin, 
almost as difficult to eradicate as epithelioma itself. It has 
been cauterized, curetted, and salved from century to cen- 
tury until the patience of all concerned has been tried to 
the utmost. Where other measures failed, the problem of 
scientific and satisfactory operative cure, with a minimum 
of disfigurement, was at last solved by von Esmarch in 
1885, who excised the diseased tissue and filled in the de- 
fect by skin grafts. - It remained for Urban, however, 1 in 
1892, to develop this form of treatment and bring it into 
general use. 

It is true that lupus had occasionally been removed pre- 
vious to this, and the defects filled in with new skin; but 
scraping instead of excision was nearly always resorted to, 
and plastic surgery relied upon to fill the gap. 2 Some- 
times, however, a Reverdin grafting was done 3 with fair 
results, although contractions took place and unsightly scars 
remained. Recurrence was frequent by either method. 

In many instances Thiersch grafting is satisfactory, 

iDeut. Zeitschr. f. Chir., Bd. 34, 1892, p. 187. . 

2 Blasius, Oppenheim's Zeitsch., Bd. XIX — Friedberg, Chir. Kim., Jena, 
1855. 

3 Roux, Revue Med., Apr. 15, 1885. 

90 



GRAFTING IN" LUPUS 91 

while in others it may be better to resort to the Wolfe- 
Krause method, in which the entire thickness of the skin 
is employed. The former is more easily and quickly ac- 
complished, and perhaps more certain of success ; while the 
latter is at times preferable on account of the superior 
durability of the new skin and its greater resemblance to 
the surrounding surface. Where it is desirable to trans- 
plant hairs, in the replacement of an eyebrow, for instance, 
the procedure of Krause is indicated, although not always 
successful. Of course ; where the raw surface can easily 
be covered by flaps, or by undermining the skin and sutur- 
ing, this should be done, but it is not often practicable, 
owing to the situation or the extent of the disease. 

It should be mentioned that all authorities do not agree 
upon the operative treatment of lupus. Some cling to the 
older methods, and maintain that various combinations of 
scraping and cauterization are to be preferred. For in- 
stance, Schutz 4 and Brooke 5 speak unfavorably of excision 
and subsequent grafting, maintaining that it is "too de- 
pendent for its success on either unknown or unpreventable 
factors ; and in private practice it is not easy to get patients 
or their friends to submit to the loss of a second slice from 
another part of the body. Further, the cosmetic effects are 
doubtful, and the removal of the disease by excision is un- 
certain." 

In reality, however, if the operation is properly done, 
recurrences are much less frequent than by other methods, 
as has been abundantly demonstrated ; and in addition, one 
who is affected with lupus and who appreciates the stub- 

*Arch. Derm. u. Syph., Bd., XVII, Heft 1, 1894. 
5 Med. Chron., Apr., 1894. 






92 SKIN" GRAFTING 

bornness of the disease should be as willing to have it ex- 
cised and the surface grafted as if it were carcinoma, 
especially as the chances of speedy recovery with compara- 
tively slight disfigurement are greater than are offered by 
other procedures. 

As in malignant growths, everything depends upon 
thorough excision ; and if this is not accomplished the oper- 
ation is a failure. The encircling incision should lie at 
least 2, and better 3, millimeters within the sound skin; 
and the entire cutis, including most of the subcutaneous 
cellular tissue, must be removed. The reason for this ex- 
tensive dissection lies in the fact that small foci, invisible to 
the naked eye, frequently exist far from the apparent bor- 
ders of the diseased area, and may be left behind unless 
considerable apparently sound tissue is sacrificed. Bruce 
Clarke 6 considers that the outlines of the disease may be 
more exactly defined by a preliminary injection of tubercu- 
lin. 

A different knife from the one used in removing the lupus 
should be employed in cutting the grafts, in order to avoid 
the somewhat remote possibility of transferring the disease. 
It is also well to be careful in regard to fingers and sponges. 

If the lupus is very • extensive, there may be reason for 
operating in two or more stages. In such cases a part only 
is cut out, and the wound grafted. Eight or ten days must 
elapse before the operation is repeated ; and it is then well 
to remove a portion of the grafts which have already been 
applied, which may have been invaded on their edges by 
tubercles. 

As the entire thickness of the skin is excised in the oper- 

6 Lancet, Mar. 18, 1893. 



GRAFTING IK" X-RAY BURNS 93 

ation, the thin Thiersch grafts sink quite decidedly below 
the surface. This hollow fills up, however, in two or three 
weeks ; and in ten or twelve weeks the new skin approaches 
the color of that which surrounds it, although it may re- 
main somewhat paler. The only situation in which much 
shrinkage occurs is about the eyelid, when nearly all of 
it has been removed. Almost the entire skin of the nose, 
especially that over the bony framework, can be cut away 
and replaced by either Thiersch or Wolfe grafts with quite 
good results. 

Care must be taken that the grafts are not shifted during 
the vomiting which often follows anesthesia. About the 
neck a plaster casing may be required to secure the neces- 
sary quietude, and it may even be desirable in certain situa- 
tions to apply no dressing at all, or merely strips of pro- 
tective, or a single layer of gauze, or a wire-mesh "cage" 
(see p. 49). 

X-ray Burns. 

With the introduction of the Roentgen-ray came the so- 
called x-ray burn — a peculiarly stubborn form of chronic 
dermatitis, in which there is atrophy of the various con- 
stituents of the true derm, often with areas of epithelial 
proliferation, resembling papillomata, and a strong ten- 
dency to bacterial invasion, ulceration, and malignant 
degeneration (Fig. 22). There is but little inclination 
toward spontaneous healing, so that it is sometimes neces- 
sary to excise the diseased area, especially if there is a 
possibility of malignancy. When this is done, transplanta- 
tion of skin may be required, by either the Thiersch or the 
Wolfe-Krause method (Fig. 23). 



94 



SKIN GRAFTING 



It has been the experience of the writer that when the 
thinner grafts are used, they may in time undergo degen- 




Fig. 22. — X-ray dermatitis of hip treated daily for one year by unskilled 
operator for tuberculosis of hip. Areas of malignant degeneration (Dr. 
H. G. Stover). 

erative changes similar to those for which they were orig- 
inally applied, hence, when practicable, it is better to 




1 2 

Fig. 23. — (1) X-ray burn of hand. (2) Same after skin grafting. (From 
Journal Medical Research, Vol. XXI, No. 3, 1909.) 

employ transplantations from the whole thickness of the 
skin. Because of their greater durability, Wolfe-Krause 



GRAFTING IN X-RAY BURNS 95 

grafts should always be preferred about the knuckles, the 
wrists, and the tips of the fingers. In operating it is neces- 
sary to remove all the burned area, if possible, as the 
disease will otherwise tend to i reappear around the edges 
of the grafts. 

According to Porter, 7 especial care must be used in these 
transplantations. For instance, hemostasis must be abso- 
lute, the dressings should be applied with moderately firm 
pressure, and the hand, for this is the part usually affected, 
should be kept somewhat elevated for at least two weeks. 
It is best to bevel the borders of the wound and cut the 
grafts to fit exactly, in one piece, with their edges thinner 
than their centers to correspond with the bevel. 

When rubber protective is used as a covering, it should 
be removed in from 24 to 3 G hours; and if there are any 
collections of serum or blood, the grafts must be incised, 
and the fluid pressed out. The edges of the transplanta- 
tions are then smeared with lanolin. 

From the experience of others, it seems unlikely that 
this elaborate technic has many advantages over other 
measures, because, if the diseased area is completely ex- 
cised, as it should be, the surface to be grafted does not 
differ from that of an ordinary wound. The writer has 
certainly had good success with the methods in common 
use. About the hands it is often difficult to check oozing. 
When this is the case, instead of prolonging the anesthetic, 
the grafts may be preserved on rubber protective in an 
aseptic jar containing moist gauze and applied without 
anesthesia on the following day (see p. 46). When the 
oozing is not excessive, however, it may almost always be 

7 J. A. M. A., Jan. 23, 1909, p. 323. 



96 . SKIN GEAFT1NG 

stopped by placing the grafts in position and applying 
temporary pressure (seep. 37). 

Grafting on the Cranium. 

Occasionally a woman's long hair is caught in a revolv- 
ing belt in some factory, and the scalp more or less com- 
pletely stripped from the skull, everything down to the 
pericranium being torn away, sometimes from the back of 
the neck to the eyelids and from one ear to the other. If 
these extensive wound surfaces are left to themselves, heal- 
ing will go on for a certain distance around the edges, 
accompanied by much contraction; but if the central por- 
tion ever heals, which is doubtful, the delicate cicatrix 
will require many months for its formation and will read- 
ily break down again. Hence the problem of successful 
skin grafting upon a denuded cranium becomes one of con- 
siderable importance. 

The Reverdin method has been most often employed, 8 
but Thiersch grafting gives much better and quicker re- 
sults and should be the operation of choice, although whole 
thickness grafts are occasionally applicable, especially when 
they can be obtained from the lost scalp, large portions of 
which may thus be utilized at times. 

Schaef er 9 has written an excellent article on the use of 
Reverdin grafts in these cases. He concludes that the 
grafts should be thick, even to comprising some of the 
subcutaneous connective tissue, should be placed close to- 
gether, and should be taken as far as may be from the 
patient's own body. The aim should be to obtain a cutane- 

8 Originally, perhaps, by S. C. Bartlett, Am. Jour. Med. Sci., Oct. 1872, p. 
573. 

9 Trans. 9th Internat. Med. Cong., Vol. Ill, p. 166. 



GRAFTING OH" THE: CRAjSTUM 97 

ous covering for the bone containing at least a good share 
of glandular elements and as movable as possible. He 
states that : "The most reliable skin is formed by grafting 
about the circumference of the wound, say one or two rows, 
producing a narrow strip 1 centimeter wide, and waiting 
until the blood-vessels are well developed in it ; then plant 
another series close to the last one. By this plan, contrac- 
tion in the marginal tissue takes place in advance of the 
subsequent graftings, diminishing the liability for an ulcera- 
tive process to occur by means of such contraction." The 
grafts are also more likely to grow well, as much of their 
nourishment is derived, according to Schaef er, from the bor- 
ders of the wound. 

Because of the poor blood supply afforded by bare bone, 
it is often better not to operate at once, but to wait until 
granulation has become well established, when transplanta- 
tion may be clone directly upon the uncuretted surface. 
In order to prevent drying out and exfoliation of the bone 
during the interval of waiting, it should be covered with 
moist dressings or with rubber protective (Davis 10 ). 

Scalping by Indians is luckily rare at present, but in the 
early times many an inhabitant of the border towns carried 
on the crown of his head a section of white and denuded 
bone which refused to become covered, even with granula- 
tions. Sneve calls attention to an almost forgotten 
method which was once employed in the cure of these trou- 
blesome cases. An unknown French surgeon was the in- 
ventor of the process, which was first described by 
Robertson. 12 

10 Ann. Surg., Dec, 1910, p. 721. 

11 Med. News, Mar. 4, 1893, p. 239. 

12 Nashville Journal of Medicine and Surgery, Apr., 1855. 



98 SKIN GRAFTING 

With a drill, a number of holes are bored close to- 
gether through the outer table of the skull, through which 
granulations push their way in the course of four or five 
weeks and coalesce upon the outside. In order to prevent 
the drill penetrating too far, a piece of cork may be fas- 
tened % inch from the end. Use may occasionally be 
found for this old method at the present time in certain 
cases. 

A positive danger, however, is sepsis, which is peculiarly 
apt to be grave in connection with the diploic structures (in 
a case reported by Pond 13 the patient's temperature went 
up to 105°), but with proper precautions the danger can 
be reduced to a minimum. 

The Eye. 

Much attention has always been given to grafting in con- 
nection with the eye, and most of the early skin transplan- 
tations were made upon the lids for the purpose of correct- 
ing ectropion. Von Grafe is said to have succeeded as 
early as 1818. These operations were given a definite 
footing, however, by Wolfe, of Glasgow, in the years be- 
tween 1872 and 1875. His first experiments were made 
by shifting small pedunculated flaps from one portion of 
the conjunctiva to another; but although he was success- 
ful in this, the range of applicability was so small and the 
available material so limited that he soon began to obtain 
grafts from the conjunctivas of rabbits. 14 

Von Wecker, it is true, has transplanted from one human 
conjunctiva to another, but opportunities for this exist 
practically only when another eye is to be enucleated un- 

13 Med. Rec, Dec. 16, 1893, p. 772. 
"Glasgow Med. Jour., 1873, p. 220. 



GRAFTING ON THE EYE 99 

less one desires to experiment with the cadaver. Mncons 
membrane from the prolapsed rectum of a child has also 
been used. 

Wolfe's cases of symblephaeon were probably the first 
ever remedied by transplantation from animals, and his 
operations were almost uniformly successful. He was 
closely followed by Raymond, Brettauer, 15 Becker, 16 von 
Wecker, and many others, both in this country and abroad. 
His method, given in his own words, is as follows ir : 

I first separate the adhesion by means of blunt-pointed scissors, 
so that the eyeball can move in any direction. The conjunctival sac 
and cornea, are cleared of nodules., so as to obtain an even surface. 
Two rabbits are then put under chloroform, one being kept in reserve 
in case of accident. 

I take from the rabbit that portion of the conjunctiva which lines 
the inner angle, covering the "membrana nictitans" and extending 
as far as the cornea, on account of its vascularity and looseness. If 
the palpebral opening is too narrow, I enlarge it at the external angle, 
and introduce a ligature through the whole thickness of the free 
border of the lower lid, and by means of the ligature the lid is drawn 
open and kept steady, and the conjunctival cul-de-sac exposed. Into 
the middle of the flap to be removed a black silk ligature is intro- 
duced, a knot is tied, and the ligature cut short. This knot is in- 
tended to mark the epithelial surface of the membrane, for without 
it the flap is apt to curl up, and leave us at a loss how to adjust it. 

Xext I mark the boundary of the conjunctiva of the rabbit which 
I wish to transplant, by inserting four black silk sutures which I 
.secure with a knot. The ligatures having been put on the stretch, I 
separate the conjunctiva to be removed with scissors, and by means 
of a fine spatula I spread it upon the back of my left hand. The 
four ligatures are then cut off, and the conjunctiva trimmed to the 
proper size. It should be larger than the lost substance. 

I now return to the patient and see that the bleeding has sub- 
sided and that the parts are in a fit condition to receive the trans- 
planted flap, which has in the meantime become dry like a piece 
of parchment, and adherent to the dorsum of the hand. It is then 
lifted by means of a spatula and transferred to replace the lost con- 
junctiva of the patient. It is secured in its place by six or eight 

15 Nagel's Jahresbericht der Ophth., 1873, p. 250. 

16 Wiener Med. Woch., 1874, No. 46. 

17 Lancet, Dec. 14, 1889, p. 1219. 



100 SKIN GRAFTING 

ligatures, or even more if necessary. This is a very difficult process 
requiring delicate manipulation, and the assistant must keep the 
flap in place by a spatula while it is being stitched in its new place. 
Both eyelids are closed with lint and a bandage, and kept so for 
four days. The ligatures are left in for six or eight days. 

At the present time surgeons lay much less stress upon 
the employment of sutures. 

In ectropion, after incision of the cicatrix and correc- 
tion of the deformity, von Wecker rilled in the wound with 
small grafts ; but this is. not advisable, as considerable con- 
traction will almost certainly occur. The method of 
Thiersch, and particularly that of Wolfe, will give much 
better results. It is at times not advisable to dissect out 
the cicatrix in these affections, as this would involve too 
much loss of tissue, but this is a point for judgment in in- 
dividual cases. It is generally sufficient to make a hori- 
zontal incision in the scar at least .5 centimeters from the 
border if possible, and of sufficient depth to permit the lid 
to be brought into place, a more or less oval wound of con- 
siderable size resulting. 

In order to avoid movement and consequent disturbance 
of the transplanted skin, the lids may be united by several 
stitches, without paring the edges, which are allowed to 
remain for from four clays to a week. If it is preferred, 
the lower lid may be attached to the superciliary region or 
the upper lid to the cheek by one or two sutures sufficiently 
tense to keep the tissues smooth and immovable. Both eyes 
should be bandaged. • 

Thiersch grafts require no sutures, and it is not only un- 
necessary to stitch fast the Wolfe grafts in the great ma- 
jority of cases, but it is positively harmful, on account of 
traumatism and tension. When something seems to be re- 



GRAFTING ON THE EYE 101 

quired to hold them in place, Argyll-Robertson 18 uses what 
he calls "tethering" or "cradle" stitches, which bind down 
the graft by passing back and forth across its surface, 
getting their points of fixation within the skin on either 
side. This method, however, is seldom necessary. 

Where nothing is left but the margin of the lid and the 
conjunctiva, perfectly satisfactory results may be obtained 
by either the Thiersch method or by that of Wolfe. 

Douthwaite 19 reports a case in which an , attempt was 
made to replace a lost portion of an eyelid with a section 
of lid from another individual. There seemed to be some 
show of success until the result was ruined by an accident 
occurring on the third day. 

In ectropion Knapp 20 recommends a skin grafting 
operation in which the skin is obtained from the lid itself, 
a strip being removed' from the loose folds between the 
margin and the eyebrow, where it will not be missed, and 
inserted in a longitudinal slit in the intermarginal space. 
Le Fort obtained- grafts in a similar manner for use in 
cases of symblepharon. Woodruff 2 1 inserts a Thiersch 
graft obtained from the red margin of the lower lip. 

Symblepharon can be successfully treated by means of 
cutaneous Thiersch grafts, as well as with mucous mem- 
brane from the lip, conjunctiva from the eyes of rabbits, or 
grafts from the skin of the lid. 

Hotz 22 employs Thiersch grafts obtained from behind 
the ear as a substitute for conjunctiva, especially after the 
removal of a pterygium. For a long time the graft re- 

18 Practitioner, 1893, p. 160. 

19 China Med. Miss. Jour., June, 1892. 

20 Oph. Rev., July, 1895. 

21 Ann. Oph. and Otol., July, 1893. 

22 Jour. Am. Med. Assoc, Sept. 10, 1892; Ann. Oph. and Otol., 1893, Vol. 
II, No. 2; Ann. Oph., Jan., 1897, p. 10. 



102 SKIN GRAFTING 

mains as "an opaque white strip covered by a thick coat of 
soft epidermic cells/ 7 but finally "loses its cutaneous char- 
acter, and can be distinguished from the ocular conjunctiva 
by very close inspection only." He concludes that "the 
skin grafting method can prevent the recurrence of ptery- 
gium, and that it leaves no unsightly mark upon the eye- 
ball. It is a comparatively simple operation, and the 
grafts so seldom fail to grow fast to their new bed that I 
feel much disposed in the future to employ this method 
in all kinds of pterygia, small and large." 

After dissecting the pterygium from the cornea and 
globe, he does not divide its base, but allows the growth 
to retract into the corner of the eye where it remains. A 
large wound in- the conjunctiva results from upward and 
downward retraction. The graft is made considerably nar- 
rower than the longitudinal diameter of the wound, in order 
that it may riot push out over the cornea, which it is in- 
clined to do, but it reaches the conjunctiva at both ends 
vertically. Both eyes should be bandaged for 48 hours. 

Successful operations by the method of Hotz have been 
reported frequently. Eversbusch 23 has also used Thiersch 
grafts upon the ocular conjunctiva, while Le Fort has em- 
ployed Wolfe grafts from the thin, loose skin of the lid. 
The writer has suggested that the lining membrane of an 
egg, or the epithelium raised by a blister, might possibly 
be employed to advantage in replacing portions of the con- 
junctiva. 

The entire internal surface of thei orbit may be covered 
with epithelium by the Thiersch method, as was done by 
von Noorden, 24 following the excision of an extensive car- 

23 Munch. Med. Woch., 1887, Nos. 1 and 2. 
^Berl. Klin. Woch., 1892, No. 41. 



GRAFTING on the ear 103 

cinomatous growth. After the removal of the globe, em- 
barrassing contractions in the socket, which interfere with 
the wearing of an artificial eye, can sometimes be pre- 
vented by judicious grafting. 

Numerous attempts have been made to replace a dam- 
aged comea in man with the cornea of an animal. For 
this purpose the rabbit has usually been selected, although 
Gradinego 25 employed the ordinary barn fowl. Most of 
the cases do reasonably well for a few days, but the new 
cornea soon becomes cloudy and useless, at least in part, 
so that the operation has been discarded by many. Its 
consideration is hardly in place in the present connection. 

The Ear. 

Skin grafts have been employed to close perforations 
of the: tympanum, Berthold 26 being the pioneer in this 
direction. He designates the operation myringoplasty, 
and reports some lasting cures, 27 in one of which the graft, 
which had grown thinner than when first applied, lay 
deeper than the level of the drum. When the tympanum 
is entirely gone, it is sometimes advantageous to freshen 
the granulated mucous membrane in the vicinity and cover 
it with an appropriate graft, but this does not mean that 
a new drum has been formed. 

In 1886, Berthold achieved considerable success in the 
temporary closure of perforations of the tympanum with 
portions of the vitelline membranes of hen's eggs. These 
grafts will often stay in place for months, and in some cases 
they probably grow fast, as they become more or less pink- 

25 Lancet, June 29, 1889, p. 1319. 

26 Monatschr. f. Ohrenheilkunde. Nov., 1878. 
2 -Ber. Klin. Woch., June 9. 1890. p. 523. 



104: SKIN GRAFTING 

isli and cannot be displaced by inflation of the internal ear ; 
in fact, it is otherwise difficult to understand how they can 
remain so long in position. 

The teehnic of the procedure is simple. The portion of 
fresh membrane, cut to an appropriate size, is placed in 
position with a pair of forceps and smoothed out with cot- 
ton on a probe ; or it may be picked up on the end of a 
medicine dropper by means of slight suction, and rede- 
posited in proper position by forcing a little air from the 
instrument. 

The troublesome granulating surfaces resulting from 
operations upon the mastoid may be successfully covered 
with Thiersch grafts as suggested by Siebenmann, 28 as may 
also fresh wounds, even when the bone is extensively ex- 
posed. Mann 29 employs for this purpose scrapings of 
epidermis mixed with blood, according to the method of 
Mangoldt (see p. 81). The wound is tamponed with 
iodoform gauze for five days, and then cauterized with 
nitrate of silver, bone and all, every two or three days until 
a good granulating surface is obtained, which will be in 
about two weeks. An anesthetic may then be given, and the 
surface curetted, although this is not essential, after which 
the epithelial paste is applied and covered with rubber pro- 
tective, which is held in place by inserting into the cavity 
pellets of gauze the size of a pea. When possible, the 
dressing should be left undisturbed for a week or more. 

28 Schmidt's Jahrbuch, B. 248, No. 12, p. 266. 
29 Deut. Med. Woch., Nov. 28, 1895, p. 798. 



CHAPTER X 
.LOCAL ANESTHESIA IN SKIN GEAETING 

Skin grafting is essentially a minor operation; hence 
whenever possible it should be clone under local anesthesia, 
thus sparing the patient the discomforts and dangers of 
chloroform or ether, although it should be understood that 
disappointment may result with children and with those 
who are especially nervous, apprehensive, or hysterical. 

The most satisfactory technic is perhaps the following: 
Have in readiness two syringes which will stand steriliza- 
tion by boiling — one, an ordinary hypodermic syringe with 
a small sharp needle, and the other a larger instrument, 
holding an ounce or more, with a moderately long needle. 
Also an anesthetizing solution consisting of : 

• Novocain 0.25 gram. 

Xornial salt sol 50.00 grams. 

Adrenalin 3 gram. 

This may be designated Sol. No. 2, and when diluted 
with an equal volume of salt solution, forms Sol. No. 1. 

The adrenalin must be fresh, and the solution prepared 
just before using. Boiling does not injure the novocain, 
but this should be done before the adrenalin is added. As 
much as 60 or 90 grams of No. 2 can be used in adults 
without danger, while No. 1 can be injected in almost any 
reasonable quantity. 

Select an area upon the arm or thigh large enough to 

105 



106 



SKIN GKAFTING 



obtain from it easily all the grafts required, and anesthe- 
tize a number of spots along its vertical center, an inch or 
so apart, with Sol. No. 1 (Fig. 24). This is done by 
thrusting the needle of the small syringe just beneath the 
epithelium, and parallel to its surface, without penetrating 
entirely through the skin. When the piston is pressed, a 
small, white elevation, or wheal, appears, which is imme- 
diately anesthetic. 

Then through these anesthetic spots the operative field' 




Fig. 2i. — Points for insertion of local anesthetic in skin grafting. 

is subcutaneously infiltrated by means of the larger syringe, 
injecting the fluid, in the direction of the arrows (Fig. 24), 
first to one side and then to the other. This should be done 
Avhile the needle is being pushed forward in order to avoid 
depositing the liquid within a vein. Massage of the part 
will produce a more thorough distribution. 

It is necessary to wait for from 5 to 15 minutes before 
the operation is begun, in order to obtain satisfactory an- 
esthesia, and this time can be occupied in completing tbe 



LOCAL ANESTHESIA 107 

surgical cleaning of the part. It is interesting to note 
the blanching of the skin due to vascular contraction under 
the influence of the adrenalin, the lessening of absorption 
thus obtained not only increasing the efficiency of the novo- 
cain, but decreasing its general poisonous effects. 

Sol. No. 1 may be used almost ad libitum for this infil- 
tration. Sol. JSTo. 2, however, acts more promptly and 
thoroughly, but the quantity employed should never greatly 
exceed two ounces. Anesthesia usually lasts from half an 
hour to an hour or more. 

Some years ago Halsted, of Baltimore, introduced a 
method for producing anesthesia of the antero-lateral por- 
tion of the thigh in skin grafting, by freezing or cocainiz- 
ing the external cutaneous nerve below the anterior superior 
iliac spine. The procedure, however, is rather difficult 
and uncertain and does not compare practically with the 
method just described. 

Thiersch grafts may also be cut, more or less painlessly, 
after freezing the skin with ethyl chlorid; but consider- 
able discomfort is experienced at the moment the tissues 
congeal, and the anesthesia is too transitory to be com- 
pletely satisfactory, hence the method is not in general 
favor. 



CHAPTER XI 

HISTOLOGY AND PATHOLOGY 

Much work in the histology of skin grafting has been 
done by Garre, 1 Goldmann, 2 Abraham and Bidwell, 3 
Thiersch, 4 and others. Most of the investigations were 
made with especial reference to the method of Thiersch ; 
but they apply equally well to Reverdin grafts, which are 
really small Thiersch grafts, and to a considerable extent 
to other forms of transplantation. 

Adhesion and Nutrition. 

Epithelial grafts, and those containing in addition more 
or less of the true skin, become adherent to granulations 
or fresh wound surfaces much as does the layer of epi- 
thelium which floats out on the surface of an ulcer from 
its borders. 

For a time its existence can be said to be parasitic ; any 
extraneous nutrition which it may receive being obtained 
by a species of imbibition from the subjacent tissues, and 
from the disintegration of leucocytes which rapidly accu- 
mulate beneath the grafts and work their way in a few 
hours into the interstices and into empty vessels, where 
they are still to be seen in considerable numbers at the 
end of eight weeks (Karg). The process was accurately 
observed in grafts five, to eight days old by Armaignach, in 

1 Cent. f. Chir., 1890, p. 226; Beitrage z. Klin. Chir., 1889, SonderaMruck. 

2 Beitrage Z. Klin. Chir., Bd. XI, Heft. 1, p. 229. 

3 Medical Week, 1894, p. 186. 

4 Verhand. d. deut. Gesell. f. Chir., 1874, p. 69. 

108 



nBHOM^mi 



HISTOLOGY AXD PATHOLOGY 109 

1877. 5 The leucocytes, together with exuded fluids, assist 
also in cementing the new skin in position, as in the heal- 
ing of an ordinary wound. In the course of eighteen hours 
(Thiersch), delicate vessels, consisting of endothelial walls 
alone, from capillary loops of the granulations and from 
vessels which form parallel to the surface, force their way 
into the severed capillaries of the graft, sometimes, pos- 
sibly, directly joining with them; while others pass into 
the tissues in various directions. The old vessels quickly 
degenerate (Garre). 

The intermediate layer of leucocytes, together with any 
coagulated blood which may be present, soon disappears, a 
layer of fibroblasts appearing in its place, and a delicate 
subcutaneous connective tissue rapidly forms. Garre has 
discovered a thin panniculus adiposus as early as the 
twenty-second day. 

The grafts become firmly adherent by the tenth day, and 
the circulation is established sufficiently well to maintain 
their vitality, although it is many weeks before the repara- 
tive process is complete. Inflammation and stasis are the 
factors which most often contribute to breaking down of 
the new skin by interfering with its nutrition. 

Color. 

The grafts are at first dead white in color, although those 
comprising the entire skin may be of bluish or reddish 
appearance owing to stagnated blood. Later on they as- 
sume a pinkish hue as the circulation becomes reestab- 
lished, which is about the sixth day or even earlier. 
Rarely, as mentioned by Krause, the vessels dilate until an 

5 Rev. de Sci. Med., Vol. 9, 1877, p. 325. 



110 SKIN GEAFTIWG 

unsightly vascular network occupies the place of the new 
skin. 

Transplanted skin tends to assume more and more the 
color of its surroundings, differing in this respect from a 
cicatrix, which increases in whiteness with its age, due to 
the presence of contracting fibers in the scar which slowly 
cut off the circulation. 

Enderlen 6 claims to have demonstrated that extensive 
degenerative changes always take place in transplanted 
skin, the only portions which survive being the lowermost 
epithelial layer, some glands and vessels, and perhaps a few 
connective tissue cells, but this is disputed by others 
(Braun) . Regeneration of epithelium proceeds from these 
structures, but the new cutis arises from the adjacent and 
subjacent tissues. 

Movability. 

Thiersch grafts gradually become movable, often in six 
or eight weeks, and may be shoved from side to side and 
even elevated in folds. This movability depends upon the 
presence of elastic fibers (Zenthoefer), which Garre has 
found as early as the tenth day, and Goldmann in abun- 
dance at the end of four months, the old fibers disappearing 
and being replaced by new ones. Urban maintains that 
movability is more apt to be present if grafting is done 
upon a fresh wound surface. 

Grafts comprising the entire skin are, of course, more 
pliable than those which are thinner, while the skin pro- 
duced by Reverdin grafting is but little looser than an 
ordinary cicatrix. Cicatricial tissue contains no elastic 

6 Centralbl. fur. Chir., No. 28, 1897, p. 7. 



HMHMM 



HISTOLOGY AND PATHOLOGY 111 

fibers, and consequently, wherever a space is left between 
two grafts, the cuticle will be more or less bound down at 
that point. Inflammation retards the formation of elastic 
fibers and may stop it altogether. 

Sensation, etc. 

Sensibility to touch and to variations of temperature 
returns slowly, and may always remain somewhat below 
normal. It begins near the edge of the graft and appears 
last at the center. 7 Two or three months are generally 
required for its complete return. 

In Reverdin and Thiersch grafting the hairs and glan- 
dular elements of the skin are absent ; but in thicker grafts 
this is not true, although the hairs are apt to be deformed 
and to fall out easily. 

In spite of many assertions to the contrary, Braun 8 
maintains that in autoplastic transplantations, where the 
conditions are favorable, the entire graft maintains its 
vitality, whether it comprise the entire thickness of the 
skin, or the epithelial layers only. Other observers, how- 
ever, claim that the more superficial layers invariably die 
and are afterwards regenerated. 

Cicatricial Contraction. 

That some contraction often goes on beneath any sort 
of skin graft cannot be denied, especially if granulations 
have been present and have not been thoroughly removed. 
This- contraction is considerable in the Reverdin method, 
where the grafts are small and far apart, and it is quite 
noticeable when strips of skin are not placed near enough 

7 Stransky, Wien. Klin. Woch., 1899, Nos. 2 and 3. 
8 Zent, f/Chir., 1911, No. 29, p. 35. 



112 SKIN GRAFTING 

to each other in the method of Thiersch or of Wolfe. 
Thiersch contended that contraction is due to the trans- 
formation of the upper layer of large, soft granulations 
into connective tissue, and that the thorough scraping away 
of these granulations would prevent its occurrence. 

Examinations made by G-arre and by Goldmann demon- 
strated that even four to eighteen months after a Thiersch 
transplantation no cicatricial tissue could be detected be- 
neath the grafts ; but this is probably not true in all cases. 
Since then it has been shown that transplantation can often 
be made directly on a granulating surface with almost as 
good a result as if the most thorough curetting had been 
performed. 

It seems probable that septic processes have much to do 
with cicatricial contraction, and that the prevention of sup- 
puration by the application of new epithelium is a matter 
of prime importance. The statement of Meyer 9 that 
Thiersch grafting is always accompanied by marked con- 
traction if the entire thickness of the skin has been lost 
is not strictly true if the grafts have been placed so as to 
properly overlap each other, although slight shrinking may 
often be noticed, especially when a considerable portion 
of a loose structure, such as the eyelid, has been replaced. 

The surfaces even of Wolfe grafts may sometimes become 
wrinkled in the course of time from contraction beneath. 
An irregular, brownish pigmentation may also occur, or 
the graft may remain cyanotic from enlarged vessels. 
These unusual phenomena cause embarrassment to all con- 
cerned, unless the patient has been previously warned. 

9 Deut. Med. Woch., No. 16, 1894. 



fcabMfc,t€ 



HISTOLOGY AND PATHOLOGY 113 

Exfoliation. • 

Exfoliation of the epidermis may occur in any form of 
transplantation, and depends largely npon nutrition, hence 
the sooner the circulation becomes thoroughly established 
the sooner will the epithelium cease to scale off. Accord- 
ing to Jungengel, a layer of clot of a certain thickness will 
always cause exfoliation, and if too thick the graft will 
die. Circulatory disturbances may also give rise to the 
formation of blisters, which may contain more or less 
blood. 1ST one of these accidents necessarily mean that the 
transplanted skin will not live, for if the rete Malpighii 
remain, the lost epithelial covering will soon be reproduced. 

Depressions. 

A remarkable thing about grafting according to Thiersch 
and Wolfe is the readiness with which depressions fill up 
to a level with the surrounding skin. This also depends 
largely upon nutrition, and is commensurate with it. On 
the nose a depression as deep as the skin is thick may 
smooth out in two or three weeks, and on the forehead, in 
from four to six weeks ; but in the case of a badly nourished 
leg a hollow may always remain. When Wolfe grafts pro- 
ject above the skin, as they often do when placed upon 
granulations, they soon become depressed to the general 
level. 

It is quite evident from the above that definite healing 
of the new skin does not take place for weeks or even 
months, and that it should not be too much exposed to 
injury before considerable time has elapsed. 



114: SKIN" GRAFTING 

Production of Epithelium. 

It was formerly maintained that the new epithelium 
appearing between skin grafts, especially in the Keverdin 
method, was produced directly from the embryonic cells 
of granulation tissue, by what Gubler has termed catabiotic 
action. In other words, these cells merely receive a sort 
of stimulus from the transplanted material, which mani- 
fests itself not only in proximity to the grafts, but also 
at the borders of the ulcer. This idea has been sup- 
ported by many eminent authorities, including Keverdin, 
Billroth, Cornil and Eanvier, Rindfleisch, Reclus, and 
others. 

Bryant was among the first to assert the untruthfulness 
of the theory, basing his opinion upon the fact that a por- 
tion of skin which he transplanted from a negro to a white 
man increased considerably in size. Since then it has been 
abundantly demonstrated that epithelium is always repro- 
duced from epithelium or endothelium and never from con- 
nective tissue or anything else, and that the "islands" of 
epithelium which occasionally appear near the centers of 
large granulating surfaces arise either frorn isolated hair 
follicles and glands, or from stray epithelial cells which 
have been accidentally transplanted. The process of cell 
division (caryocinesis) has been observed and studied in 
grafts. 

Epithelium seems to possess a strong independent vital 
ity which renders it almost parasitic. Other tissues 
possess this also, but to a far less degree ; for, if such were 
not the case, accidentally severed portions of fingers, ears, 
and noses could not be replaced, as has been so often done, 



■.'"...•.;■■•'■.,.' vf? 



HISTOLOGY AND PATHOLOGY 115 

and the transplantation of bone, nerves, tendons, brain- 
tissue, etc., would be impossible. 

Independent Longevity of Epithelium. 

Martin 10 made a number of experiments to determine 
the length of time during which grafts could live when 
separated from the body. The longevity increased with 
the decline of the temperature, the best results being 1 ob- 
tained near the freezing point, when vitality was main- 
tained for 96 hours. The time could be increased to 108 
hours, however, by keeping the grafts in a confined space 
instead of in the open air. An amputated limb, for in- 
stance, if kept in a refrigerator, can be used for grafting 
purposes at least 21 hours after its removal from the body. 

It is more than probable that these experiments of Mar- 
tin do not show the duration of vitality of the grafts so 
much as they do the time of beginning decomposition under 
varying circumstances. In other words, if the pieces of 
epithelium had been maintained in an aseptic condition, 
vitality might have been greatly if not indefinitely pro- 
longed. 

Since the researches of Martin, numerous experiments 
have demonstrated, clinically and otherwise, that skin 
grafts may be conserved for varying lengths of time before 
their transplantation (Thiersch, Minnich, Menzel, Brewer, 
etc.). Hoclgen n and Lusk 12 have shown that dried epi- 
thelium, even when detached from the body, will retain its 
vitality, and Lusk 13 was able to preserve such desiccated 
fragments indefinitely and use them successfully in graft- 

10 Thesis, Paris, 1873. 

11 St. Louis Med. and Surg. Jour., July, 1871. 

12 Med. Rec, Dec. 7, 1895, p. 800. 

13 Internat. Jour. Surg., Feb. 1897, p. 39. 



116 SKIN GRAFTING 

ing. This is not surprising when we remember that no 
greater enemy to bacterial growth exists than dryness. 

The experiment reminds one of the dried grain preserved 
for so many centuries in the pyramids of Egypt, which, 
under the influence of heat and moisture, is capable of ger- 
mination and reproduction. It naturally suggests itself 
whether the epithelium of a mummy would not do likewise 
under favorable circumstances. 

This independent vitality accounts, to a certain extent, 
for the comparative readiness with which epithelium may 
be transplanted, and for the manner in which it grows 
over, or "floats" out, upon a granulating surface; but we 
must also recognize an ability to imbibe sufficient nourish- 
ment for at least temporary maintenance without direct 
vascular communication with the underlying tissues. 

In this connection another interesting fact, first noticed by 
Klebs, is the power possessed by epithelial cells to "wan- 
der" from the borders of an ulcer out on the granulating 
surface, which may help to explain the independent islands 
of skin which sometimes appear. 

Epithelial Stimulation. 

Undoubtedly the epithelium at the edge of an ulcer is 
stimulated to renewed growth by the presence of grafts 
within a reasonable distance, and the grafts also stimulate 
one another; the greater the number of grafts, and the 
closer they lie to each other, the greater the stimulation. 

This can be accounted for by assuming that growth is in- 
hibited by the presence of bacteria and their poisons, as 
well as by defective circulation and nutrition. When a 
graft begins to adhere and develop, it destroys the bacteria 



HHH^HUHI^^BHIJHlH 



HISTOLOGY AND' PATHOLOGY 117 

over a certain area and weakens those in its immediate 
vicinity, besides increasing the flow of nutritive fluids. 
These phenomena turn the balance in favor of the epithe- 
lium as against -the germs. 

It has been claimed by some 14 that this "stimulation" 
is greatest shortly following transplantation, and hence bet- 
ter results are obtained in the method of Eeverdin by 
grafting in successive stages and by placing a row of grafts 
near the margin of the granulating surface at each sitting. 
There is little evidence, however, to support this assertion. 

Grafting From the Negro to the White Man. 

Under ordinary circumstances no one would think of 
transplanting the skin of a negro to a white man, or the 
reverse ; so that the question as to whether or not the skin 
will retain, under such conditions, its original color is of 
scientific interest only. The experiment has been tried a 
number of times (once resulting in a lawsuit), but the 
reports have been strangely conflicting. 

That skin removed from an individual of one race and 
grafted upon a member of a different race will grow with- 
out difficulty was demonstrated by Maurel, 15 who per- 
formed many experiments in this line, although Thiersch 
claims that, while skin from the negro will grow perfectly 
well upon a white man, white skin will not do well upon 
the negro. Fowler 16 says that when white skin is trans- 
ferred to a negro the white color remains. 

Bryant 17 records an apparently convincing case m 
which a number of small pieces of negro's skin were grafted 

14 Charles Steele, Brit. Med. Jour., Dec. 10, 1870. 
15 Gaz. Med., 1878, p. 349. 

16 Ann. Surg., Vol. 9, 1889, p. 179. 

17 Figs. 52 & 53, p. 136, Bryant's Surgery. 



118 SKIN GRAFTING 

upon the leg of a white man. These increased to twenty 
times their original size within ten weeks, and coalesced 
to form a comparatively large patch of black cuticle. 
Hodgen confirmed Bryant's conclusion, when the deeper 
portions of the epithelium were transplanted, but not when 
superficial epithelial scales were alone employed. The 
writer once transferred a portion of black skin from 
the thigh of a negro to the comparatively white sole of the 
patient's foot. At the end of about three weeks, when the 
man was lost sight of, the graft still retained its dark 
color. 

Eeverdin, and also Coste, declare that black grafts soon 
lose their characteristic color upon a white man, from ab- 
sorption of their pigment; and Maurel, whose experience 
was large, stated that pigmented grafts must be trans- 
planted to individuals whose skins are rich in pigment if 
they are to retain their color. 

Thiersch, in his investigation of the subject, came to 
the conclusion that skin of one color when transplanted to 
individuals of another color always changed its hue. 
Girdner 1S noticed a gradual transformation from black 
to white in the skin transplanted from a negro to a white 
man. Maxwell 19 transferred a small graft from his own 
arm to the face of a colored man; "from the size of a 
canary seed, it increased to the extent of about a half inch 
in its greater dimensions and was of irregular form, with 
narrow points extending into the surrounding black sur- 
face." Presently dark lines appeared in the white skin, 
and in the course of three months it was as black as the 
remainder of the negro's countenance. 

is Med. Rec, Oct. 25, 1890, p. 468. 

19 Phila. Med. Times, Oct, 8, 1873, p. 37. 



MHHiHi 



HISTOLOGY Am> PATHOLOGY 119 

A study of the subject has been made by Karg, 20 who 
concluded that white skin gradually became black upon a 
negro, and vice versa. He showed that pigment was 
carried to and from the epidermis by the phagocytic action 
of large star-shaped connective-tissue cells lying on the 
border between the corium and epidermis and that it was 
finally removed by wandering corpuscles. Karg contended 
that the pigment was formed in the rete, although Thiersch 
believed that its formation took place still deeper. Of 
some value in this connection is the undisputed fact that 
the skin of frogs when transplanted soon loses its pigmenta- 
tion and almost becomes transparent. 

The majority of testimony seems to indicate that the 
color of grafts finally changes to that of the skin into which 
they are transplanted ; but this transformation takes place 
slowly, and may not be completed for many weeks. We 
should expect the time to vary considerably, as the activity 
of the pigment cells depends largely upon the nourishment 
of the epithelium in general. Those who claim that this 
change does not take place may have reported their cases 
too soon; and in the absence of evidence to the contrary, 
we shall have to assume that this is true. 

Cheloids. 

Occasionally a cheoloid growth springs up between the 
grafts or around the borders of the transplanted area. 
This has been particularly mentioned by Murray, Lange, 
Kammerer, McBurney, and Fowler. 21 Sometimes this is 
a true cheloid, but more frequently merely redundant 
cicatricial tissue due to spaces being left between the 

20 Arch, f.; Anat. and Phys., 1888; Cent. f. Chir., 1888, p. 944. 

21 N. Y. Med. Jour., Feb. 4, 1893. 



120 SKIN GRAFTING 

grafts, which become the seat of irritating bacterial infec- 
tion. 

McBurney is inclined to hold the dry dressing responsi- 
ble for these cicatricial overgrowths, and recommends the 
employment of a moist covering for the grafts for at least 
two weeks. This idea is scarcely tenable, however, as the 
same formation often occurs under wet dressings. The 
causes of true cheloid are not at all clear, but they are 
probably the same in connection with skin . grafting as 
under other conditions. 

Fowler records a case in which he removed from the 
arm a cheloid which had followed vaccination, and grafted 
the wound with frog's skin. The growth promptly re- 
turned. Two more attempts were made, one with the skin 
of a chicken and the other with cuticle from the patient's 
own thigh, but each time the cheloid again made its ap- 
pearance ; and following the last operation a growth of the 
same nature sprang up in the thigh from which the graft 
was obtained, which discouraged the operator from fur- 
ther interference. 

A peculiar case was observed by Pilcher, 22 in which, as 
soon as the patient got out of bed following a transplanta- 
tion, an eruption resembling purpura, eventually forming 
blisters, appeared, not only upon the grafts but upon the 
surface from wdiich they were obtained. As soon as the 
bed was resumed, the eruption disappeared, but developed 
a second time when the patient attempted to walk about. 

Intense itching occasionally appears after a few days at 
.the seat of a transplantation, which can often be relieved 
by massage. 23 

22 N. Y. Med. Jour., Feb. 4, 1893. 

23 Garre, Brit. Med. Jour., Mar. 9, 1889, p. 560. 



HISTOLOGY ANH PATHOLOGY 121 

An epithelioma was seen by Dunham 24 on the leg of a 
woman of 53, following Reverdin grafting of an old ulcer. 
Such an isolated case signifies little, however, as epithe- 
liomata occasionally develop in crural ulcers where no 
transplantation has been attempted. 

24 Med. Bee, Aug. 3, 1895, p. 170. 



CHAPTER XII 

BRIEF COMPARISON OF DIFFERENT METH- 
ODS OF SKIN GRAFTING 

The simplest of all is the method of Reivebdin. It is 
easy of execution, causes but little pain, and is but slightly 
suggestive of a dreaded "operation" ; but the results are not 
always satisfactory. The new epidermis is often but little 
better than ordinary scar tissue, having a marked tendency 
to contraction, and breaking down under comparatively 
slight provocation. This is particularly true when the 
grafts are small, thin, and far apart.- If, on the other 
hand, they are too thick, the new skin will be more or less 
"humniocky" on its surface. In addition, the alternation 
of the darker grafts with the lighter intervening cicatricial 
areas often produces a mosaic appearance which is some- 
times quite objectionable. Movability is seldom obtained, 
because the epidermis is bound down by connective tissue 
between the grafts and cannot be loosened by massage. 

Hence transplantation according to Reverdin should be 
reserved for cases in which for some reason it is inexpedi- 
ent to employ another method, and where the rapid closure 
of a granulating surface is desired without much reference 
to anything else. Examples of such instances are : ( 1 ) 
When the patient refuses to have the skin removed from 
his own person, and it becomes necessary to procure it 

from another individual; it can then be snipped out in 

122 



COMPARISON OF METHODS 123 

small pieces where a more extensive operation would be 
refused. (2) When, after the different operations with 
their several advantages have been explained, the patient 
chooses the method in question on account of its compara- 
tively trivial nature. (3) When, in very old or weak or 
nervous people, a general or a local anesthetic would be 
undesirable. 

Much of course depends upon the situation of the lesion 
and its nature. A loss of tissue upon the face naturally 
requires more consideration for cosmetic reasons than, an 
ulcer of the leg, and the chance of embarrassing contrac- 
tures about the joints and neck must be avoided even at 
the expense of much inconvenience and some danger. Un- 
der the various circumstances just mentioned, one may re- 
sort to dead bodies, preferably those of .infants, or to 
amputated limbs; or obtain the necessary. material from a 
case of circumcision, or from the skin of some animal. 
And just here is where a real use may be found for epi- 
dermis obtained from warts, corns, callosities, blisters, 
etc., and for "epidermal dust," although we must not ex- 
pect the results to be very brilliant. 

Thiersch grafting- has a wider range of applicability 
than any other method, and its results are quite uniformly 
good, both functionally and cosmetically, and yet it must 
give way to other proceedings under certain conditions, 
where firmer and thicker skin is desirable which more 
closely resembles the surrounding integument. 

In such cases the WoefehKrause method should be 
chosen. This is particularly true upon the palms of the 
hands, the soles of the feet, the eyelids, and possibly about 
the face in general, although Thiersch grafts answer the 



124: SKIN" GKAFTING 

purpose fairly well in the last-named situation. The 
thicker grafts, when they can be made to unite, un- 
doubtedly furnish a more durable covering for old leg 
ulcers, especially of the varicose variety, and to parts about 
the joints. 

The transplantation of hairs can be accomplished only 
by taking the entire thickness of the skin, and even then the 
result is apt to be unsatisfactory. 

It is seldom desirable to employ grafts comprising the 
subcutaneous fat, as recommended by Hirschberg. 

The skin" of animals does not compare in vitality with 
that derived from the patient's own body or from some 
other person, and just where its employment would be 
most serviceable — on the leg ulcers of old people, for in- 
stance — it is next to useless. 

Mucous membbane, from animals and from man, Can 
be used to repair defects in the urethra, vagina, etc., and 
the conjunctiva of rabbits makes an excellent substitute 
for that membrane in the human species ; but it has been 
sufficiently well shown that Thiersch grafts and skin flaps 
will often answer the same purpose, 1 while they are more 
easily obtained, are much more likely to be successful, and 
they can be kept more nearly aseptic. If cutaneous grafts 
do not actually become transformed into mucosa, they at 
least come, in the course of time, to resemble it closely. 
Even in the urethra, skin flaps and Thiersch grafts have 
been used, although with the former epithelial exfoliation 
is apt to lead to subsequent annoyance. 

In the transplanting of skin and of mucous membrane, 
it must always be borne in mind that heterogeneous graft- 

iWitzel, Cent. f. Chir., No. 45, 1890. 



COMPARISON OF METHODS 125 

ing is much less likely to succeed than autogenous, hence 
the material should always be obtained from the patient 
himself if possible. 



INDEX OF AUTHORITIES QUOTED 



Abraham and Bidwell, 108 
Agnew, 18 
Aievoli, E., 88 
Allen, 85, 86 
Altamirano, 87 
Amat, 88 

Argyll-Robertson, 100 
Armaignach, 108 



Baratoux and Dubousquet-Labor- 

derie, 85 
Barker, E., 42 
Bartlett, S. C, 96 
Becker, 99 
Beigel, 77 
Bell, John, 5, 6 
Berger, 20 
Bernhard, 52 
Berthold, 89, 103 
Bidwell, 28 
Billroth, 114 
Blasius, 90 
Braun, 110, 111 
Brettauer, 9*9 
Brewer, 115 
Brooke, 91 
Bryant, 23, 114, 117 
Biinger, 5 



Cheyne, 46 

Church, 85 

Clark, Bruce, 45, 92 

Colrat, 84 

Cornil and Ranvier, 114 

Coste, 118 

Cousin, 84 

Czerny, 9, 74, 78, 81 



Davis, 8, 16, 28, 36, 40, 45, 51, 

67, 69, 70, 73, 83, 97 
Deuvel, 9 



Dieffenbach, 75 
Dobson, 7 
Donnelly, 18 
Doolittle, 41 
Douthwaite, 101 
Dunham, 48, 60, 121 
Dunn, 11, 26 
Dzondi, 5 

E 

Eiselberg, von, 67 
Enderlen, 110 
Esmarch, von, 2, 90 
Eversbusch, 102 



Fen wick, 77 

Fidder, 81 

Finney, 6 

Fioravanti, Sir Leonard, 5 

Fischer, 33, 37 

Fowler, 20," 46, 47, 86, 117, 119, 

120 
Franke, 40 

G 

Garengeot, 5 

Garre, 108, 109, 110, 112, 120 

Girdner, 81, 118 

Gnarch, 62 

Goldmann, 51, 108, 110, 112 

Gould, 2 

Grafe, von, 98 

Gr anbury, 20, 79 

Gubler, 114 

H 

Hahn, 10 

Halsted, 39, 42, 48, 107 
Hamilton, 14, 81 
-Banff, 75 
Harte, Richard, 18 
Hartley, 11 

Hirschberg, 20, 69, 70, 74, 78, 
124 



127 



128 



INDEX OF AUTHORITIES QUOTED 



Hodgen, 13/ 79, 80, 81, 115, 118 

Hoffacker, 6 

Hotz, 101, 102 

Howard, 80 

Hiibscher, C, 39, 87 

Hueter, 18, 25, 70 

Hunter, John, 3 



Ivanova, 7, 81 



Jacenko, 68 
Jungengel, 44, 67, 113 

K 

Kammerer, 119 

Karg, 108, 119 

Kelley, 6 

Kelloek, 46 

Kibler, 79 

Klebs, 116 

Knapp, 101 

Kraske, 15, 55, 57, 62 

Krause, 70, 71, 109 



Lange, 119 

Lanz, 54 

Leale, 79 

Le Fort, 68, 101, 102 

Lewis, 19 

Lucas, 19 

Lusk, 80, 115 

Lynngren, 46 

M 

McBurney, 39, 40, 48, 53, 119, 

120 
McCarthy, 28 
McNaught, 45 
Mangoldt, 81, 104 
Mann, 81, 104 
Marcy, 28 
Martin, 115 
Maurel, 117, 118 
Maxwell, 118 
Menzel, 115 
Meyer, 112 
Miles, 85, 87, 88 
Minnich, 115 
Mixter, 41 
Morris, 80 
Morrow, 75 



Moullin, 46 
Munoz, 13 
Murray, 119 



N 



Nancrede, 66 
Nesterovsky, 86 
Noorden, von, 63, 102 
North, 26 
Nussbaum, von, 80 







Oilier, 20, 33 



Page, David, 13 
Parmenter, 14, 79 
Parry, 51 
Pilcher, 120 
Pitschke, 74 
Plessing, 47, 67 
Polaillon, 86 
Pollock, 13 
Poncet, 21 
Pond, 98 
Porter, 46, 47, 95 
Pusey, 20 

R 

Raven, 87 

Ravmond, 99 

Reclus, 81, 84, 114 

Redard, 87 

Reverdin, 20, 21 , 80, 114, 118 

Rindfleisch, 114 

Roberts, 25 

Robertson, 97 

Robinson, 83 

Roux, 90 

Rushmore, 37 



Sancassani, 4 

Schaefer, 9, 96, 97 

Schepelmann, 52 

Schmieden, 26, 56 

Schnitzler and Ewald, 38, 65 

Schrady, 1 

Schutz, 91 

Schweninger, 80 

Sick, 39, 78 

Siebenmann, 104 

Smith, 23, 85 

Souchon, 23 



INDEX OF AUTHORITIES QUOTED 



129 



Steele, 81, 117 
Stover, H. G., 94 
Stransky, 111 
Sullivan, 7 
Symonds, 81 



Tagliacozza, 4 

Taylor, 69 

Thiersch, 39, 48, 75, 108, 109. 

115, 118, 119 
Thies,' 52 
Thompson, 43 
Thorndike, 67 
Tillmanns, 63 

U 
Urban, 58, 60, 64, 65, 90, 110 



Van Helmont, 4 
Van Meter, M. E. 



87 



Virchow, 68 
Vogel, 45 



W 



Watson, 88 

Weeker, von, 98, 99, 100 

Wentscher, 46 

Wilcox, 40 

Witzel, 124 

Wolfe. 68, 78, 98, 99 

Woodruff, 101 



Young, 71 



Zenthoefer, 110 



INDEX 



Accidental wounds, Thiersch grafting in, 60 

Accordion grafts in method of Thiersch, 54 

Acne rosacea, Thiersch grafting in, 61 

Adhesion in grafting, 108 

Adjustment of grafts and dressings in method of Wolfe-Krause, 72 

After-treatment in method of Reverdin, 32 

of Thiersch, 56 

of Wolfe-Krause, 72 
Amputated limbs, grafting from, 81 
Anaplasty, 1 

Anesthesia, local, in grafting, 105 
Anesthetics in method of Thiersch, 47 
Anomalies in grafting, 79 
Antiseptics in method of Reverdin, 18, 24 
Aseptics in grafting, 12 
Autodermic grafts, 3 

B 

Bacillus pyocyaneus, 30 
Bedsores, Thiersch grafting in, 64 
Blood, grafting in, 29 
Bone, grafting on, 62 
Bovinine, 29, 48 

Burn, treatment of, by Thiersch grafting, 59 
Burns, Thiersch, grafting in, 60 
x-ray, grafting in, 93 

O 

Cage, wire-gauze, 49 

Callosities, grafting from, 79 

Cancer, transmission of, 10 

Cantharides blister in grafting, 80 

Case reports of Thiersch grafting, 58 

Cauterization in method of Reverdin, 17 

Changing dressings in method of Reverdin, 30 

Cheloids in grafting, 119 

Chickens, grafting from, 87 

Chronic empyema, Thiersch grafting in, 63 

Cicatricial contraction in grafting, 111 

tissue in method of Reverdin, 16 
Cleanliness, surgical, 12 
Cock's wattle, grafting from, 87 
Color in grafting, 109 
Comparison of methods of grafting, 122 

131 



132 • INDEX 



Compression in method of Eeverdin, 17 
Condition of patient in grafting, 10 
Contraindications in grafting, 10 
Contraction in grafting, cicatricial. 111 
Contractures, Thiersch grafting in, 62 
Cornea, grafting on the, 103 
Corns, grafting from, 79 
Cranium, grafting on the, 96 
Curetting in method of Thiersch, 38 
Cutting grafts, Halsted method of, 42 
in method of Reverdin, 21 
in method of Thiersch, 34, 40 



Dead bodies, grafting from, 81 

Death from skin grafting 11 

Definitions, 1 

Depressions in grafting, 113 

Dermanoplasty, 2 

Dermepenthis, 2 

Dermo-epididermal grafts. 2 

Diabetes as contraindication in grafting, 10 

Disease, influence of. in grafting. 10 

transmission of, 9 
Dressings in method of Reverdin, 27 
changing, 30 
wet and dry, 29 

of Thiersch, 48 

of Wolfe-Krause, adjustment of, 72 



E 

Ear. grafting on the, 103 

Ectropion, grafting in. 100. 101 

Egof. lining membrane of. grafting from, 88 

Elkoplasty. 14 

Empyema, chronic, Thiersch grafting in, 63 

Epidermal dust, 2 

grafts, 2 
Epidermis, exfoliation of, 31. 113 

grafting from, 80 
Epithelial dust, grafting from, 80 

stimulation in grafting, 116 
Epithelioma, treatment of, by Thiersch grafting, 59 
Epithelium, longevity of, in grafting, 115 

production of, in grafting. 114 
Erysipelas as contraindication in grafting, 10 
Esmarch strap. 35, 39, 69, 75 
Europe, early history in, 4 

Excision of hairy moles, Thiersch grafting in, 62 
Exfoliation in grafting, 113 

cf epidermis, 31 
Eye, grafting on the, 98 



INDEX 133 



Fingers, Thiersch grafting on, 62 

Foot, crushed, treatment of by Thiersch grafting, 58 

Frogs, grafting from, 85 

G 

Gauze for holding grafts in place, 28 
Grafting, adhesions in, 108 

anomalies in, 79 

cantharides blister in, 80 

cheloids in, 119 

cicatricial contraction in, 111 

color in, 109 

comparison of method of, 112 

depressions in, 113 

epithelial stimulation in, 116 

exfoliation in, 113 

from amputated limbs, 81 

from animals, 84, 124 

from callosities, 79 

from chickens, 87 

from cock's wattle, 87 

from corns, 79 

from dead bodies, 81 

from epidermis, 80 

from epithelial dust, 80 

from frogs, 85 

from kittens, 87 

from lining membrane of an egg, 88 

from moles, 79 

from mucous membrane, 124 

from muscle, 80 

from negro to white man, 117 

from puppies, 87 

from rabbits, 87 
testes of, 88 

from warts, 79 

hairs in, 80 

heterogeneous Thiersch, 66 

histology of, 108 

in blood, 29 

in ectropion, 100, 101 

in lupus, 90 

in operations on the mastoid, 104 

in perforations of the tympanum, 103 

in pterygium, 101 

in scalping, 97 

in symblepharon, 99, 101 

•in two stages in method of Thiersch, 46 

in x-ray burns, 93 

local anesthesia in, 105 

longevity of epithelium in, 115 

mortality in, 110 

nutrition in, 108 

on bone in method of Thiersch, 63 



134 INDEX 

Grafting — cont'd 

on the cornea, 105 

on the cranium, 96 

on the ear, 103 

on the eye, 98 

on the orbit, 102 

pathology of, 108 

production of epithelium in, 114 

proper time for, in method of Thiersch, 55 

sensation in, 111 

sponge, 82 
Grafts, accordion, in method of Thiersch, 54 

adjustment of, in method of Wolfe-Krause, 72 

autodermic, 3 

cutting, Halsted method of, 42 
in method of Reverdin, 21 
of Thiersch, 34, 40 

dermo-epidermal, 2 

epidermal, 2 

from prepuce of a child, 19 

from the old and from the young, 7 

from the scrotum, 20 

Hamilton-Reverdin, 14 

heterodermic, 3 

heterogeneous, 8 

homodermic, 3 

isodermic, 3 

placing the, in method of Reverdin, 24 
of Thiersch, 43 

primary fixation of, 51 

Reverdin, 13 

size of, in method of Reverdin, 20 

skin-periosteum-bone, 76 

splinting, in method of Thiersch, 51 

Thiersch, 33 

thin vs. thick, in method of Thiersch, 46 

total cutaneous, 2 

treatment of wounds after removal of, in method of Thiersch, 53 

vegetable, 2 

where to obtain, in method of Reverdin, 18 

whole-thickness, 2 

Wolfe-Krause, 68 

zoodermic, 3 
Granulations in method of Reverdin, 15 

of Thiersch, preparation of, 39 
Greffe dermique, 21 

dermoepidermique, 21 

H 

Hairs in grafting, 80 

transplantation of, 124 
Halsted method of cutting grafts, 42 
Hamilton-Reverdin method, 14 

Hand, crushed, treatment by Thiersch grafting, 58 
Hands, Thiersch grafting on, 62 
Healing, process of, in method of Reverdin, 31 



no>Ex 135 



Hemorrhage in method of Thiersch, 37 
Heterodermic grafts, 3 
Heterogeneous grafting, 8 

Thiersch, 66 
Hirschberg, method of, 74 
Histology of skin grafting, 108 
History, early, 3 

in Europe, 4 

in India, 3 
Homodermic grafts, 3 

Implantation, 2 

Incisions, radiating, in method of Reverdin, 18 

India, early history in, 3 

Indian method of transplantation, 2, 74 

Inflammatory processes in method of Reverdin, 17 

Instition, 2 

Isodermic grafts, 3 

Italian method of transplantation, 2 

K 

Kittens, grafting from, 87 



Laudable pus, 16 

Legal questions in skin grafting, 26 
Local anesthesia in grafting, 105 
Longevity of epithelium in grafting, 115 
Lupus, grafting in, 90 

method of Reverdin in, 90 

of Thiersch in, 90 

of Wolfe-Krause in, 91 

M 

McBurney hooks for stretching skin, 41 
Mastoid, grafting in operations on the, 104 
Method of Hamilton-Reverdin, 14 
of Hirschberg, 74 
of Reverdin, 13, 122 

after-treatment in, 32 

antiseptics in, 18, 24 

cauterization and compression in, 17 

cicatricial tissue in, 16 

dressings in, 27 
changing, 30 
wet and dry, 29 

granulations in, 15 

in lupus, 90 

inflammatory processes in, 17 

method of cutting grafts in, 21 

on cranium, 96 

placing the grafts in, 24 

preparation for, 15 

process of healing in, 31 



136 hsdbx 

Method of Reverdin — cont'd 
radiating incisions in, 18 
size of grafts in, 20 
suppuration in, 16 
where to obtain grafts in, 18 
of Thiersch, 33, 123 
accordion grafts in, 54 
after-treatment in, 56 
anesthetics in, 47 
application of, 57 

case reports of, 58 
curetting in, 38 
cutting grafts in, 34 
dressings in, 48 
general technic of, 33 
grafting in two stages in, 46 

on bone in, 63 
hemorrhage in, 35 
heterogeneous grafting in, 66 
in accidental wounds, 60 
in acne rosacea, 61 
in bedsores, 64 
in burns, 60 
in chronic empyema, 63 

leg ulcers, 64 
in incising hairy moles, 62 
in lupus, 90 
in special cases, 60 
method of cutting grafts in, 40 
on cranium, 96 
on hands and fingers, 62 
on mucous surfaces, 65 
on scars and contractures, 62 
on the nose, 60 
placing the grafts in, 43 
preparation of granulations in, 39 
proper time for grafting in, 55 
splinting grafts in, 51 
statistics in, 66 
thin vs. thick grafts in, 46 
treatment of crural ulcers by, 58 

of crushed foot by, 58 

of crushed hand by, 58 

of epithelioma by, 59 

of extensive burn by, 59 

of ulcer of leg by, 59 

of wounds after removal of grafts in, 53 
of Wolfe-Krause, 68, 123 

adjustment of grafts and dressings in, 72 
after-treatment in, 72 
in lupus, 91 
preparation for, 69 
technic of, 70 
Methods of grafting, comparison of, 122 
Moles, grafting from 2 79 

hairy, Thiersch grafting in excision of, 62 
Movability in grafting, 110 



INDEX 137 



Mucous membrane, transplantation of, 77, 124 

surfaces, Thiersch grafting on, 65 
Muscle, grafting from, 80 
Myringoplasty, 103 

N 

Negro to white man, grafting from, 117 
Nephritis as contraindication in grafting, 10 
New growths, Thiersch grafting in, 61 
Nose, Thiersch grafting on the, 60 
Nutrition in grafting, 108 



O 



Old, grafts from the, 7 
Orbit, grafting: on the, 102 



Pathology of skin grafting, 108 

Placing the grafts in method of Reverdin, 24 

of Thiersch, 43 
Preparation for method of Reverdin, 15 
of Wolfe-Krause, 69 
of granulations in method of Thiersch, 39 
Prepuce of a child, grafts from, 19 
Primary fixation of grafts, 51 
Production of epithelium in grafting, 114 
Pterygium grafting in, 101 
Puppies, grafting from, 87 
Pus, laudable, 16 

R 

Rabbits, grafting from, 87 

testes of, 88 
Reverdin, method of, 13, 122 

after-treatment in, 32 

antiseptics in, 18, 24 

cauterization and compression in, 17 

cicatricial tissue in, 16 

dressings in, 27 
changing, 30 
wet and dry, 29 

granulations in, 15 

in lupus, 90 

inflammatory processes in, 17 

method of cutting grafts in, 21 

on cranium, 96 

placing the grafts in, 24 

preparation for, 15 

process of healing in, 31 

radiating incisions in, 18 

size of grafts in, 20 

suppuration in, 16 

where to obtain grafts in, 18 
Rubber tissue for skin grafting, 27 



138 INDEX 

s 

Scalping, grafting in, 97 
Scarlet red ointment, 29, 56 
Scars, Thiersch grafting on, 62 
Scrotum, grafts from the, 20 
Sensation in grafting, 111 
Size of grafts in the method of Reverdin, 20 
Skin-periosteum-bone grafts, 76 
Smallpox, transmission of, 9 
Splinting grafts in method of Thiersch, 51 
Sponge grafting, 82 
Statistics in Thiersch grafting, 66 
Stimulation, epithelial, in grafting, 116 
Suppuration in method of Reverdin, 16 
Surgical cleanliness, 12 
Symblepharon, grafting in, 99, 101 
Syphilis as contraindication in grafting, 11 
transmission of, 9 



Technic of method of Thiersch, 33 

of Wolfe-Krause, 70 
Terminology, 1 

Testes of rabbits, grafting from, 88 
Thiersch, method of, 33, 123 

accordion grafts in, 54 

after-treatment in, 56 

anesthetics in, 47 

application of, 57. 
case reports of, 58 

curetting in, 38 

cutting grafts in, 34 

dressings in, 48 

general technic of, 33 

grafting in two stages in, 46 
on bone in, 63 

hemorrhage in, 35 

heterogeneous grafting in, 66 

in accidental wounds, 60 

in acne rosacea, 61 

in bedsores, 64 

in burns, 60 

in chronic empyema, 63 
leg ulcers, 64 

in excising hairy moles, 62 

in lupus, 90 

in special cases, 60 

method of cutting grafts in, 40 

on cranium, 96 

on hands and fingers, 62 

on mucous surfaces, 65 

on scars and contractures, 62 

on the nose, 60 

placing the grafts in, 43 



INDEX 139 

Thiersch, method of — cont'd 

preparation of granulations in, 39 
splinting grafts in, 51 
statistics in, 66 
thin vs. thick grafts in, 46 
treatment of crural ulcers by, 58 
of crushed foot by, .58 
of crushed hand by, 58 
of epithelioma by, 59 
of extensive burn by, 59 
of ulcer of leg by, 59 

of wounds after .removal of grafts in, 53 
Total cutaneous grafts, 2 
Transmission of cancer, 9 
of disease, 9 
of smallpox, 9 
of syphilis, 9 
of tuberculosis, 9 
Transplantation, 2 
Indian method, of, 2 
Italian method of, 2 
of hairs, 124 

of mucous membrane, 77, 124 
Treatment of wounds after removal of grafts in method of Thiersch, 53 
Tuberculosis, transmission of, 9 
Tympanum, grafting in perforation of the, 103 

U 

Ulcer of leg, treatment of, by Thiersch grafting, 59 
Ulcers, chronic leg, Thiersch grafting in, 64 
. crural, treatment of, by Thiersch grafting, 58 



Vegetable grafting, 2 

W 
Warts, grafting from, 79 
White man, grafting from negro to, 117 
Whole-thickness grafts, 2 
Wire-gauze cage, 49 
Wolfe, technic in symblepharon, 99 
Wolfe-Krause, method of, 68, 123 

adjustment of grafts and dressings in, 72 

after-treatment in, 72 

in lupus, 91 

preparation for, 69 

technic of, 70 

X 

X-ray burns, grafting in, 93 

Y 

Young, grafts from the, 7 

Z 

Zoodermic grafts, 3 
Zoografting, 84 



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